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Mills AC, Marinelli B, Klein ED, Garcia-Reyes K, Shilo D, Nowakowski S, Patel R, Patel R, Kim E, Fischman A, Bishay V, Loudon H, Stone J, Lookstein R. Fertility after Transcatheter Arterial Embolization for Obstetric Hemorrhage: An Urban Health Care System Observational Study. Am J Perinatol 2024; 41:e1257-e1263. [PMID: 36858070 DOI: 10.1055/s-0043-1761917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
OBJECTIVE This study aimed to investigate pregnancy rate, pregnancy outcomes, and resumption of menses after transcatheter arterial embolization (TAE) for obstetric hemorrhage (OH). STUDY DESIGN Sixty-seven patients who underwent TAE for OH from 2006 to 2020 within an urban, multihospital health care system were identified retrospectively. Selected patients were interviewed by phone to complete a survey with a primary outcome of self-reported pregnancy in those seeking pregnancy. Secondary outcomes included pregnancy outcomes and resumption of menses. Univariate testing of association of pregnancy and miscarriage rate with embolic agent was performed using Fisher's exact test. RESULTS Thirty-three of 50 patients (66%) meeting the inclusion criteria completed the survey on fertility, a median of 47 (range, 13-123) months after TAE for OH. Of the 13 patients who attempted pregnancy, there was a pregnancy rate of 77% and miscarriage rate of 38%. Those who delivered live newborns conceived spontaneously, carried to term, and delivered a healthy newborn via cesarean section at a weight appropriate for gestational age. Thirty (91%) patients resumed menstruation, and the majority with unchanged frequency. Most patients underwent bilateral uterine artery embolization with radial artery access (54%). The most common embolic agents used were gelfoam only (30%) and glue only (24%). There was no statistically significant association between embolic agent and pregnancy or miscarriage rate. CONCLUSION Spontaneous pregnancy with live birth and resumption of menses can occur in a majority of patients after TAE for OH. KEY POINTS · Most patients who attempted pregnancy after TAE for OH achieved pregnancy.. · Most patients who became pregnant conceived spontaneously and delivered healthy newborns at term.. · Most patients resumed menstruation after TAE for OH.. · There was no significant association between type of embolic and pregnancy or miscarriage rate..
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Affiliation(s)
- Ariana C Mills
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brett Marinelli
- Biomedical Engineering and Imaging Institute, Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emma D Klein
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kirema Garcia-Reyes
- Division of Vascular and Interventional Radiology, Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dan Shilo
- Division of Vascular and Interventional Radiology, Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Scott Nowakowski
- Division of Vascular and Interventional Radiology, Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rahul Patel
- Division of Vascular and Interventional Radiology, Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rajesh Patel
- Division of Vascular and Interventional Radiology, Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Edward Kim
- Division of Vascular and Interventional Radiology, Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Aaron Fischman
- Division of Vascular and Interventional Radiology, Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Vivian Bishay
- Division of Vascular and Interventional Radiology, Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Holly Loudon
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joanne Stone
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
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Costumbrado J, Snyder L, Ghassemzadeh S, Ng D. Vaginal Bleeding Due to Iatrogenic Uterine Perforation - A Case Report. JOURNAL OF EDUCATION & TEACHING IN EMERGENCY MEDICINE 2024; 9:V6-V9. [PMID: 38707940 PMCID: PMC11068317 DOI: 10.21980/j83643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 03/16/2024] [Indexed: 05/07/2024]
Abstract
Uterine perforation is a rare but potentially life-threatening complication of gynecologic procedures. Serious complications include hemorrhage, infection, and injury to surrounding organ systems (eg, gastrointestinal, urological, vascular, etc.). Risk factors include advanced maternal age, prior gynecologic surgeries, and other anatomical features that impact the difficulty of accessing the uterine cavity. In this case report, we discuss a patient who presented to the emergency department (ED) with diffuse abdominal pain and vaginal bleeding that occurred after an elective dilation and curettage (D&C) for a termination of pregnancy. The diagnosis was suspected clinically and confirmed by imaging including ultrasound (US) and computed tomography (CT) of the abdomen and pelvis. The patient was managed operatively with a multidisciplinary approach including Gynecology, General Surgery, and Urology. The patient was stabilized and eventually discharged. Uterine perforation should be included in the differential for patients with a history of recent gynecologic instrumentation presenting with abdominal pain and vaginal bleeding. The stabilization of these patients requires aggressive volume resuscitation, controlling the source of bleeding, and emergent surgical consultation. Topics Gynecology, vaginal bleeding, ultrasound, computed tomography.
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Affiliation(s)
- John Costumbrado
- University of California, Riverside, School of Medicine, Riverside, CA
- Riverside Community Hospital, Department of Emergency Medicine, Riverside, CA
| | - Leah Snyder
- Riverside Community Hospital, Department of Emergency Medicine, Riverside, CA
| | - Sassan Ghassemzadeh
- University of California, Riverside, School of Medicine, Riverside, CA
- Riverside Community Hospital, Department of Emergency Medicine, Riverside, CA
| | - Daniel Ng
- University of California, Riverside, School of Medicine, Riverside, CA
- Riverside Community Hospital, Department of Emergency Medicine, Riverside, CA
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3
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Novatt H, Rockhill K, Baker K, Stickrath E, Alston M, Fabbri S. Clinic Versus the Operating Room: Determining the Optimal Setting for Dilation and Curettage for Management of First-Trimester Pregnancy Failure. Cureus 2024; 16:e56490. [PMID: 38638705 PMCID: PMC11026066 DOI: 10.7759/cureus.56490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/20/2024] Open
Abstract
Introduction There is no clear guidance for the optimal setting for dilation and curettage (D&C) for the management of first-trimester pregnancy failure. Identifying patients at risk of clinically significant blood loss at the time of D&C may inform a provider's decision regarding the setting for the procedure. We aimed to identify risk factors predictive for blood loss of 200mL or greater at the time of D&C. Methods This is a retrospective cohort study of patients diagnosed with first-trimester pregnancy failure at gestational age less than 11 weeks who underwent surgical management with D&C at a single safety net academic institution between 4/2016 and 4/2021. Patient characteristics and procedural outcomes were abstracted. Women with less than 200mL versus greater than or equal to 200mL blood loss were compared using descriptive statistics, chi-square for categorical variables, and Satterthwaite t-tests for continuous variables. Results A total of 350 patients were identified; 233 met inclusion criteria, and 228 had non-missing outcome data. Mean gestational age was 55 days (SD 9.4). Thirty-one percent (n=70) had estimated blood loss (EBL) ≥200mL. Younger patients (mean 28.7 years vs. 30.9, p=0.038), Latina patients (67.1% vs. 51.9%, p=0.006), patients with higher body mass index (BMI, mean 30.6 vs. 27.3 kg/m2, p=0.006), and patients with pregnancies at greater gestational age (59.5 days vs. 53.6 days, p<0.001) were more likely to have EBL ≥200mL. Additionally, patients with pregnancies dated by ultrasound (34.3% vs. 18.4%, p=0.007), those who underwent D&C in the operating room (81.4% vs. 48.7%, p<0.001), and those who underwent general anesthesia (81.4% vs. 44.3%, p<0.001) were more likely to have EBL ≥200mL. Discussion In this study, patients with EBL ≥200mL at the time of D&C differed significantly from those with EBL<200mL. This information can assist providers in planning the best setting for their patients' procedures.
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Affiliation(s)
- Hilary Novatt
- Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, USA
| | - Kari Rockhill
- Epidemiology and Public Health, Rocky Mountain Poison & Drug Safety, Denver, USA
| | - Kori Baker
- Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, USA
| | - Elaine Stickrath
- Obstetrics and Gynecology, UCHealth Women's Care Clinic, Steamboat Springs, USA
| | - Meredith Alston
- Obstetrics and Gynecology, Intermountain Health Saint Joseph Hospital, Denver, USA
| | - Stefka Fabbri
- Obstetrics and Gynaecology, Denver Health, Denver, USA
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4
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Fleurant E, McCloskey L. Medication Abortion: A Comprehensive Review. Clin Obstet Gynecol 2023; 66:706-724. [PMID: 37910067 DOI: 10.1097/grf.0000000000000812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
This chapter provides an overview of evidence-based guidelines for medication abortion in the first trimester. We discuss regimens, both FDA-approved and other clinical-based protocols, and will briefly discuss novel self-managed abortion techniques taking place outside the formal health care system. Overview of patient counseling and pain management are presented with care to include guidance on "no touch" regimens that have proven both feasible and effective. We hope that this comprehensive review helps the health care community make strides to increase access to abortion in a time when reproductive health care is continuously restricted.
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Affiliation(s)
- Erin Fleurant
- Department of Obstetrics and Gynecology, Northwestern McGaw Medical Center, Chicago, Illinois
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McLaren H, Hennessey C. First-trimester Procedural Abortion. Clin Obstet Gynecol 2023; 66:676-684. [PMID: 37750678 DOI: 10.1097/grf.0000000000000808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
First-trimester abortion is a common and safe procedure. A focused history and physical examination are essential for providing this care. Laboratory assessment can include Rh typing, hemoglobin, and cervicitis testing as indicated by a patient's risk factors. Procedural abortion in the first trimester includes cervical dilation with or without cervical preparation, and uterine evacuation utilizing a manual vacuum aspirator or electric vacuum aspirator. Complications occur rarely and are often easily managed at the time of diagnosis.
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Affiliation(s)
- Hillary McLaren
- Department of Obstetrics and Gynecology, Section of Complex Family Planning, University of Chicago, Chicago, Illinois
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6
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Swantic V, Hawley D, Zipp C, Lee N, Praditpan P. Second-trimester Abortion. Clin Obstet Gynecol 2023; 66:685-697. [PMID: 37910075 DOI: 10.1097/grf.0000000000000825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
In 2019, the US Centers for Disease Control reported that 7% of abortions were performed after 13 weeks of pregnancy, a small proportion of all terminations. However, the need for second-trimester abortions will increase commensurate with restrictions to access nationwide. Second-trimester abortions are performed with medications or through a procedure. Health care practitioners serving persons at risk of pregnancy should understand how abortions are performed and how to deliver evidence-based postabortion care. The purpose of this article is to provide a foundation for caring for individuals before, during, and after second-trimester abortion.
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Affiliation(s)
- Vanessa Swantic
- Department of Obstetrics and Gynecology, Morristown Medical Center, Morristown, New Jersey
| | - Darell Hawley
- Department of Family Medicine, Morristown Medical Center, Morristown, New Jersey
| | - Christopher Zipp
- Department of Family Medicine, Morristown Medical Center, Morristown, New Jersey
| | - Nancy Lee
- Department of Family Medicine, Morristown Medical Center, Morristown, New Jersey
| | - Piyapa Praditpan
- Department of Obstetrics and Gynecology, Morristown Medical Center, Morristown, New Jersey
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Potter LA, Ly SH, Pei X, Ponzini MD, Wilson MD, Hou MY. Characteristics and outcomes of patients undergoing second-trimester dilation and evacuation for intrauterine fetal demise vs induced abortion. Contraception 2023; 126:110118. [PMID: 37453657 PMCID: PMC10528417 DOI: 10.1016/j.contraception.2023.110118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVES Patients with intrauterine fetal demise (IUFD) are at higher risk of complications when undergoing dilation and evacuation (D&E) compared to patients undergoing abortion for other indications. We aimed to compare baseline characteristics and describe outcomes, including frequencies of complications such as disseminated intravascular coagulation (DIC) and hemorrhage, in patients undergoing D&E for IUFD vs induced abortion, with a goal of identifying associated risk factors for complications. STUDY DESIGN We conducted a retrospective matched cohort study of patients undergoing nonemergent D&Es for singleton ≥14-0/7-week IUFD January 1, 2019 to May 31, 2021, matched with two patients undergoing induced second-trimester D&Es by cesarean delivery history, patient age, and gestational age (GA). We collected demographics, history, GA, coagulation studies, quantitative blood loss (QBL), and complications. We calculated descriptive statistics and tested for association using chi-square, Fisher's exact, t, and Wilcoxon's rank sum tests. RESULTS Of 1390 procedures, 64 patients with IUFD met inclusion criteria and were matched with 128 patients undergoing induced D&E. Eight (12.5%) patients with IUFD and six (4.7%) undergoing induced D&E had hemorrhage (odds ratio [OR] = 2.90, 95% confidence interval [0.96, 8.77]). Six (9.4%) patients with IUFD and none undergoing induced D&E had DIC (OR = 28.56 [1.58, 515.38]). Median QBL was 75.0 mL (50, 162.5) for patients with IUFD vs 110.0 mL (50, 200) for those undergoing induced D&E (p = 0.083). Twelve (18.8%) patients with IUFD vs seven (5.5%) undergoing induced D&E received at least one intervention due to bleeding complications (p = 0.004). CONCLUSIONS We found a higher DIC frequency but no significant difference in hemorrhage or QBL in IUFD D&E compared to induced abortion. Our IUFD D&E complication frequency is higher than those previously published. IMPLICATIONS Our results affirm current standards of care for D&E in patients with IUFD. Large referral centers may have higher proportions of complications compared to other sites.
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Affiliation(s)
- Laura A Potter
- University of California, Davis School of Medicine, Sacramento, California, United States
| | - Serena H Ly
- University of California, Davis School of Medicine, Sacramento, California, United States
| | - Xiaohe Pei
- University of California, Davis School of Medicine, Sacramento, California, United States
| | - Matthew D Ponzini
- Department of Public Health Sciences, University of California, Davis, Sacramento, California, United States
| | - Machelle D Wilson
- Department of Public Health Sciences, University of California, Davis, Sacramento, California, United States
| | - Melody Y Hou
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, California, United States.
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8
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Cirucci CA. Self-Managed Medication Abortion: Implications for Clinical Practice. LINACRE QUARTERLY 2023; 90:273-289. [PMID: 37841380 PMCID: PMC10566489 DOI: 10.1177/00243639221128389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Medication abortion represents more than 50 percent of abortions in the United States (US). Since its approval in the US in 2000, the Food and Drug Administration (FDA) has progressively relaxed the prescribing requirements such that currently, no office visit, in-person dispensing, or ultrasound is required. Obtaining medication for abortion online without medical supervision or evaluation is also possible. This article reviews the complications of medication abortion by examining major studies and delineates the risks specific to self-managed abortion to inform clinicians in caring for women. Summary Medication abortion has become the most common abortion method in the United States. This document provides a detailed history of the relaxation requirements on medication abortion and reviews the major studies on medication abortion complications including a discussion of their limitations. Finally, the paper delineates the ease of access to medication abortion without a health care provider and the risks associated with self-managed abortion. This paper is intended to provide information for clinicians who likely will be encountering increasing number of patients with such complications.
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9
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Ozery E, Ansari J, Kaur S, Shaw KA, Henkel A. Anesthetic Considerations for Second-Trimester Surgical Abortions. Anesth Analg 2023; 137:345-353. [PMID: 36729414 DOI: 10.1213/ane.0000000000006321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Although most abortion care takes place in the office setting, anesthesiologists are often asked to provide anesthesia for the 1% of abortions that take place later, in the second trimester. Changes in federal and state regulations surrounding abortion services may result in an increase in second-trimester abortions due to barriers to accessing care. The need for interstate travel will reduce access and delay care for everyone, given limited appointment capacity in states that continue to support bodily autonomy. Therefore, anesthesiologists may be increasingly involved in care for these patients. There are multiple, unique anesthetic considerations to provide safe and compassionate care to patients undergoing second-trimester abortion. First, a multiday cervical preparation involving cervical osmotic dilators and pharmacologic agents results in a time-sensitive, nonelective procedure, which should not be delayed or canceled due to risk of fetal expulsion in the preoperative area. In addition, a growing body of literature suggests that the older anesthesia dogma that all pregnant patients require rapid-sequence induction and an endotracheal tube can be abandoned, and that deep sedation without intubation is safe and often preferable for this patient population through 24 weeks of gestation. Finally, concomitant substance use disorders, preoperative pain from cervical preparation, and intraoperative management of uterine atony in a uterus that does not yet have mature oxytocin receptors require additional consideration.
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Affiliation(s)
- Elizabeth Ozery
- From the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, California
| | - Jessica Ansari
- From the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, California
| | - Simranvir Kaur
- Department of Obstetrics & Gynecology, Division of Family Planning Services & Research, Stanford University, Stanford, California
| | - Kate A Shaw
- Department of Obstetrics & Gynecology, Division of Family Planning Services & Research, Stanford University, Stanford, California
| | - Andrea Henkel
- Department of Obstetrics & Gynecology, Division of Family Planning Services & Research, Stanford University, Stanford, California
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10
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Manning S, Kuhn D. Spontaneous and Complicated Therapeutic Abortion in the Emergency Department. Emerg Med Clin North Am 2023; 41:295-305. [PMID: 37024165 DOI: 10.1016/j.emc.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Pregnancy-related emergency department visits are common in the United States. Although typically managed safely in the outpatient setting, patients with spontaneous abortion may also present with life-threatening hemorrhage or infection. Management strategies for spontaneous abortion are similarly wide-ranging from expectant management to emergent surgical intervention. Surgical management of complicated therapeutic abortion is similar to that of spontaneous abortion. The dramatic changes in the legal status of abortion in the United States may have significant influence on the incidence of complicated therapeutic abortion, and we encourage emergency physicians to familiarize themselves with the diagnosis and management of these conditions.
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Gilbert CM, Matulich MC, Ponzini MD, Wilson MD, Creinin MD. Clinical interventions are more accurate than quantitative measurements for defining hemorrhage with dilation and evacuation. Contraception 2023; 120:109914. [PMID: 36473510 PMCID: PMC10076208 DOI: 10.1016/j.contraception.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/15/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To assess if quantitative blood loss (QBL) with dilation and evacuation (D&E) procedures correlated with clinically relevant outcomes or hemorrhage. STUDY DESIGN We used a de-identified database to review D&E procedures performed at UC Davis Health from April 2019 through March 2020. Surgeons determined QBL during procedures and estimated blood loss, when excessive, during post-procedure recovery. We extracted patient demographic and procedure-related information. We defined clinically relevant bleeding as cases with bleeding-related interventions within 24 hours post-procedure including use of ≥2 uterotonics, tranexamic acid administration, cervical injury requiring repair, uterine balloon tamponade, blood transfusion, uterine artery embolization, hospitalization, or return to operating room; the latter 5 criteria defined hemorrhage. We used χ2 test for trend to evaluate bleeding outcomes. RESULTS We evaluated 431 procedures with a mean gestational age of 19 weeks and 3 days. Clinically relevant bleeding outcomes occurred in 6/319 (2%), 15/97 (15%) and 7/12 (58%) patients with total blood loss <250mL, 250-500mL and >500mL, respectively (p<0.0001); 11 had bleeding related to cervical injuries. Hemorrhage occurred in 0, 4/97 (4%) and 5/12 (42%) patients, respectively (p<0.0001). Patients with relevant bleeding outcomes had QBLs ranging from 150-1800mL (median QBL 312.5mL, interquartile range [IQR] 250-550mL) while those without clinically relevant bleeding ranged from 10-900mL (median QBL 150mL, IQR 75-200mL). CONCLUSION Most patients (75%) with clinically relevant bleeding outcomes had QBL ≤500mL. Although higher QBL correlates with clinical interventions, the need for significant interventions rather than a single blood loss amount should be used to define hemorrhage with D&E procedures. IMPLICATIONS Clinical hemorrhage is best defined by the necessary clinical interventions required to manage bleeding rather than any quantified amount of blood loss.
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Affiliation(s)
- Cassandra M Gilbert
- University of California, Davis School of Medicine, Sacramento, CA, United States
| | - Melissa C Matulich
- University of California, Davis School of Medicine, Sacramento, CA, United States; Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA, United States
| | - Matthew D Ponzini
- Division of Biostatistics, University of California, Davis School of Medicine, Public Health Sciences, Sacramento, CA, United States
| | - Machelle D Wilson
- Division of Biostatistics, University of California, Davis School of Medicine, Public Health Sciences, Sacramento, CA, United States
| | - Mitchell D Creinin
- University of California, Davis School of Medicine, Sacramento, CA, United States; Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA, United States.
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12
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Xiang Y, Wang X, Gong Y, Xiang J. The effectiveness of motherwort injection in preventing postabortion hemorrhage after induced abortion: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e32935. [PMID: 36800587 PMCID: PMC9936024 DOI: 10.1097/md.0000000000032935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Unintended pregnancy is a problem that women encounter throughout their reproductive age. Excessive and prolonged uterine bleeding is one of the most common and critical adverse reactions of induced abortion, for it increases the risk of anemia and intrauterine infection. To provide reliable clinical evidence, we performed a protocol for systematic review and meta-analysis to evaluate the hemostatic effect of motherwort in postabortion. METHODS This review protocol has been registered in the international prospective register of systematic reviews. The statement of Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols will be used as guidelines for reporting present review protocol. Original clinical randomized controlled trials assessing the beneficial effects and safety of motherwort on induced abortion will be included. Databases searched include China National Knowledge Infrastructure, Chinese Scientific Journals Database, Wanfang Database, China Biological Medicine Database, PubMed, and EMBASE Database and Cochrane Central Register of Controlled Trials. Cochrane collaboration tool is used to assess the risk of bias of included randomized controlled trials. All calculations are carried out with Stata 11.0 (The Cochrane Collaboration, Oxford, United Kingdom). RESULTS This systematic review and meta-analysis will provide a detailed summary of the current evidence related to the efficacy of motherwort injection preventing postabortion hemorrhage after induced abortion. CONCLUSION This evidence will be useful to practitioners, patients, and health policy-makers regarding the use of motherwort injection in induced abortion.
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Affiliation(s)
- Yanjie Xiang
- Center for Reproductive Medicine, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Xiaohan Wang
- Department of Obstetrics, Rizhao Hospital of Traditional Chinese Medicine, Shandong, P.R. China
| | - Yongqian Gong
- Department of Otorhinolaryngology, The First Affiliated Hospital of Hengyang Medical School, University of South China, Hunan, P.R. China
| | - Jianfeng Xiang
- Department of Interventional Oncology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
- * Correspondence: Jianfeng Xiang, Department of Interventional Oncology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, P.R. China (e-mail: )
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Second-trimester abortion care for those with complex medical conditions. Curr Opin Obstet Gynecol 2022; 34:359-366. [PMID: 36036465 DOI: 10.1097/gco.0000000000000817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF THE REVIEW This review focuses on patients who are most likely to experience morbidity associated with second trimester abortion care and risk mitigation strategies. RECENT FINDINGS Prior cesarean birth, particularly multiple prior cesarean births, is the most significant risk factor associated with complications during second trimester abortion because of increased risks of hemorrhage, with or without placenta accreta spectrum (PAS), and distorted anatomy, which increases the risk of uterine perforation. Recent data suggests that first trimester ultrasound findings may be predictive of PAS, including multiple lacunae, abnormal uteroplacental interface, and hypervascularity. Multiple common medications interact with mifepristone and are therefore contraindicated; ulipristal shares mifepristone's selective progesterone receptor modulator activity but does not share the same metabolic pathway. Recent data suggests ulipristal may be an effective adjunct for cervical preparation, avoiding potentially mifepristone's drug-drug interactions. Those ending a pregnancy due to severe early-onset hypertensive disorders have a high rate of clinically significant thrombocytopenia: platelet transfusion is recommended for those with platelets <50 000 per cubic millimeter. SUMMARY Pregnant people presenting for care in the second trimester may have conditions that make an abortion more technically or medically complex. Clinicians can mitigate much of this increased risk with preprocedural planning, and appropriate intra-operative preparedness.
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14
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Anderson CM, Tschann M, Whitehouse K, Soon R, Fontanilla T, Kaneshiro B. Oxytocin and Hypotension During Dilation and Evacuation Procedures at 18-24 Weeks Gestation. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2022; 81:328-332. [PMID: 36504503 PMCID: PMC9727702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Oxytocin is a neurohormone that is routinely administered to patients during dilation and evacuation procedures (D&E) to control bleeding despite minimal evidence in support of this common practice. In this study, the authors sought to evaluate patients with hypotension after receiving oxytocin during D&E procedures. The secondary data from a double-blind, randomized, placebo-controlled trial involving 112 patients who underwent a D&E at 18-24 weeks gestation and prophylactically received an intravenous bolus of either 30 units of oxytocin in 500 mL of normal saline or 500 mL of saline alone at the start of the procedure were analyzed. Anesthesia providers measured blood pressure before, at the time of, and after study medication administration in 5-minute increments until the end of the procedure. No differences in demographic characteristics or mean blood pressure between the 2 groups were observed. The proportion of hypotensive patients was not statistically different at 5 minutes following fluid bolus (oxytocin 25% versus placebo 13%, P=.09). The proportion of hypotensive patients was similar by 10 minutes (oxytocin 20% versus placebo 16%, P=.62). A sample size of 112 provided the ability to detect a 23% difference in the proportion of patients who experienced hypotension (2-sided 95% CI, power of 80%). These findings suggest that oxytocin may have a transient hypotensive effect.
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Affiliation(s)
- Clare-Marie Anderson
- Department of Obstetrics and Gynecology and Women’s Health, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
| | - Mary Tschann
- Department of Obstetrics and Gynecology and Women’s Health, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
| | - Katherine Whitehouse
- Department of Obstetrics and Gynecology and Women’s Health, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
| | - Reni Soon
- Department of Obstetrics and Gynecology and Women’s Health, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
| | - Tiana Fontanilla
- Department of Obstetrics and Gynecology and Women’s Health, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
| | - Bliss Kaneshiro
- Department of Obstetrics and Gynecology and Women’s Health, John A. Burns School of Medicine, University of Hawai‘i, Honolulu, HI
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15
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Yang ST, Chang WH, Chao WT, Lai TJ, Lin WL, Lim HC, Liu CH, Wang PH. The timing of intravenous oxytocin administration is crucial to minimize perioperative blood loss during first-trimester suction curettage for missed abortion. J Chin Med Assoc 2022; 85:1061-1067. [PMID: 36083636 DOI: 10.1097/jcma.0000000000000808] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Oxytocin is commonly used to reduce blood loss during suction curettage for missed abortion. However, the potential of oxytocin to mitigate blood loss in early pregnancy remains controversial. Based on the hypothesis that the "timing" of oxytocin administration may be a critical factor, we investigated whether the timing of intravenous (IV) administration is associated with reduced perioperative blood loss during first-trimester suction curettage for missed abortion. METHODS The medical charts of 146 patients with ultrasound-confirmed first-trimester missed abortion who underwent suction curettage with IV oxytocin administration were retrospectively reviewed. RESULTS Among the patients, 67 received 10 IU of IV oxytocin before suction curettage (early-oxytocin administration group), while 79 patients received 10 IU of IV oxytocin after suction curettage (late-oxytocin administration group). The demographic features between the two groups did not significantly differ. However, there was a lower proportion of nulliparous patients in the early-oxytocin administration group than in the late-oxytocin administration group (38.8% vs 60.8%, p = 0.006). The perioperative blood loss amount was significantly lower in the early-oxytocin administration group than in the late-oxytocin administration group (60 [range: 50-100] vs 100 [range: 30-250] mL, p = 0.001). Moreover, the multivariate logistic regression analysis showed that the early-oxytocin administration group had a lower risk for a perioperative blood loss amount of ≥100 mL than the late-oxytocin administration group (0.23 [range: 0.10-0.55], p = 0.001); a gestational age of 9-12 weeks ( p = 0.009) was found to be associated with an increased risk for a perioperative blood loss amount of ≥100 mL. CONCLUSION Compared with late-oxytocin administration, early-oxytocin administration could reduce perioperative blood loss during first-trimester suction curettage for missed abortion. However, the results require further investigation.
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Affiliation(s)
- Szu-Ting Yang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Wen-Hsun Chang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Wei-Ting Chao
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Ting-Jung Lai
- Department of Obstetrics and Gynecology, Cardinal Tien Hospital, New Taipei City, Taiwan, ROC
| | - Wei-Lin Lin
- Department of Obstetrics and Gynecology, Wan Fang Hospital, Taipei Medical University, New Taipei City, Taiwan, ROC
| | - Hong-Ci Lim
- Department of Obstetrics and Gynecology, Taipei Medical University Hospital, Taipei, Taiwan, ROC
| | - Chia-Hao Liu
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Obstetrics and Gynecology, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan, ROC
- Female Cancer Foundation, Taipei, Taiwan, ROC
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16
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Bridwell R, Long B, Montrief T, Gottlieb M. Post-abortion Complications: A Narrative Review for Emergency Clinicians. West J Emerg Med 2022; 23:919-925. [DOI: 10.5811/westjem.2022.8.57929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/23/2022] [Indexed: 11/15/2022] Open
Abstract
An abortion is a procedure defined by termination of pregnancy, most commonly performed in the first or second trimester. There are several means of classification, but the most important includes whether the abortion was maternally “safe” (performed in a safe, clean environment with experienced providers and no legal restrictions) or “unsafe” (performed with hazardous materials and techniques, by person without the needed skills, or in an environment where minimal medical standards are not met). Complication rates depend on the procedure type, gestational age, patient comorbidities, clinician experience, and most importantly, whether the abortion is safe or unsafe. Safe abortions have significantly lower complication rates compared to unsafe abortions. Complications include bleeding, retained products of conception, retained cervical dilator, uterine perforation, amniotic fluid embolism, misoprostol toxicity, and endometritis. Mortality rates for safe abortions are less than 0.2%, compared to unsafe abortion rates that range between 4.7-13.2%. History and physical examination are integral components in recognizing complications of safe and unsafe abortions, with management dependent upon the diagnosis. This narrative review provides a focused overview of post-abortion complications for emergency clinicians.
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Affiliation(s)
- Rachel Bridwell
- Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington
| | - Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, Fort Sam Houston, Texas
| | - Tim Montrief
- Jackson Memorial Health System, Department of Emergency Medicine, Miami, Florida
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
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17
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Boraas CM, Carroll A, Hesse SP, Norkett E, Ralph JA. Management of Surgical Abortion Complications. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Christy M. Boraas
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Anna Carroll
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Steven P. Hesse
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Emily Norkett
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Jessika A. Ralph
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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18
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Using Prophylactic Antihemorrhagic Medications in Second-Trimester Surgical Abortions. Obstet Gynecol 2022; 140:663-666. [PMID: 36075063 DOI: 10.1097/aog.0000000000004922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/17/2022] [Indexed: 01/05/2023]
Abstract
We aimed to estimate the association of prophylactic antihemorrhagic medication use during dilation and evacuation (D&E) with operative hemorrhage and estimated blood loss (EBL). Records for all pregnant patients between 14 and less than 22 weeks of gestation who had a D&E procedure from January 2012 to December 2019 were retrospectively reviewed. Prophylactic antihemorrhagic medication use was defined as receiving vasoconstrictors, uterotonics, or both before identification of hemorrhage during a D&E procedure. Overall, 147 D&E procedures were completed at a mean of 16.4 (±2.2) weeks of gestation. Prophylactic medications were used in 72.1% (n=106) of D&E procedures. Prophylactic medication use was associated with lower operative hemorrhage (21.7% vs 51.2%, P <.01) and lower EBL (336.9 mL vs 551.3 mL, P <.01).
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19
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Xinyu X, Xintong T, Youping L, Feng W, Jiajie Y. Motherwort Injection for Preventing Uterine Hemorrhage in Women With Induced Abortion: A Systematic Review and Meta-Analysis of Randomized Evidence. Front Pharmacol 2022; 13:916665. [PMID: 35935833 PMCID: PMC9349354 DOI: 10.3389/fphar.2022.916665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/14/2022] [Indexed: 12/04/2022] Open
Abstract
Objective: Motherwort injection (MI) is a modern patented injection extracted from motherwort (Leonurus japonicus Hoult). Empirical studies and systematic reviews have shown the benefits of motherwort injection for preventing postpartum hemorrhage after vaginal delivery and cesarean section. This study was conducted to explore the efficacy and safety of motherwort injection for women with the prevention of post-abortion uterine hemorrhage. Methods: A comprehensive literature search was conducted to identify RCTs regarding the effect of the use of motherwort injection in women after abortion. Data from trials were pooled by meta-analysis and a random-effects model was used to calculate the summarized relative risks (RRs) and their 95% confidence intervals (CIs). The grading of recommendations assessment, development, and evaluation (GRADE) methodology was used to access the quality of the evidence. Results: Nine trials with a total of 1,675 participants were identified. Overall, motherwort injection combined with oxytocin compared to oxytocin had a significantly lower blood loss within 2 hours (MD = −50.00, 95% CI −62.92 to −37.08, very low quality); lower blood loss within 24 h (MD = −50.00, 95% CI −62.92 to −37.08, very low quality); however, there was no significant difference between motherwort injection and oxytocin (24 h: MD: 0.72, 95% CI −7.76 to 9.20; 48 h: MD: −0.01, 95% CI −11.35 to 11.33; 72 h: MD: −1.12, 95% CI −14.39 to 12.15, very low quality). Compared with oxytocin or no intervention, both motherwort injection and motherwort injection combined with oxytocin had a significantly decreased duration of blood loss (MI vs. O: MD −2.59, 95% CI −4.59 to −0.60, very low quality; MI + O vs. O: MD −2.62, 95% CI -3.02 to −2.22, very low quality; MI + O vs. No intervention: MD: −1.80, 95% CI −2.28 to −1.33, low quality). Seven of nine included trials reported adverse event outcomes. Three cases were found in the motherwort injection group, and five induced abortion syndromes were found in the motherwort injection plus oxytocin group. 29 adverse events were reported in the oxytocin group instead. The recovery time of normal menstruation after abortion was significantly earlier in the group using motherwort injection compared with oxytocin (MDs −3.77, 95% CI −6.29 to −1.25, very low quality), and the endometrial thickness in the motherwort injection group was significantly different from that in the oxytocin group (MD: 2.24, 95% CI 1.58 to 2.90, very low quality). Conclusion: The results of this meta-analysis indicate prophylactic use of motherwort injection may reduce the risk of uterine hemorrhage in women after abortion, and more high-quality research is needed to confirm the efficacy and safety of motherwort injection in preventing uterine hemorrhage after abortion. Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=274153, identifier CRD42021274153
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Affiliation(s)
- Xue Xinyu
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Tang Xintong
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Li Youping
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Wan Feng
- State Key Laboratory of Southwestern Chinese Medicine Resources, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yu Jiajie
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Yu Jiajie,
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Cavalari CAA, Veiga-Junior NN, Kajiura BD, Eugeni C, Tavares BVG, Baccaro LF. Factors Associated with Abortion Complications after the Implementation of a Surveillance Network (MUSA Network) in a University Hospital. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:507-512. [PMID: 34461660 PMCID: PMC10303421 DOI: 10.1055/s-0041-1735129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To evaluate the factors associated with abortion complications following the implementation of the good-practice surveillance network Mujeres en Situación de Aborto (Women Undergoing Abortion, MUSA, in Spanish). METHODS A cross-sectional study with women who underwent abortion due to any cause and in any age group at UNICAMP Women's Hospital (part of MUSA network), Campinas, Brazil, between July 2017 and Agust 2019. The dependent variable was the presence of any abortion-related complications during hospitalization. The independent variables were clinical and sociodemographic data. The Chi-square test, the Mann-Whitney test, and multiple logistic regression were used for the statistical analysis. RESULTS Overall, 305 women were enrolled (mean ± standard deviation [SD] for age: 29.79 ± 7.54 years). The mean gestational age was 11.17 (±3.63) weeks. Accidental pregnancy occurred in 196 (64.5%) cases, 91 (29.8%) due to contraception failure. At least 1 complication was observed in 23 (7.54%) women, and 8 (34.8%) of them had more than 1. The most frequent complications were excessive bleeding and infection. The factors independently associated with a higher prevalence of complications were higher gestational ages (odds ratio [OR]: 1.22; 95% confidence interval [95%CI]: 1.09 to 1.37) and contraceptive failure (OR: 3.4; 95%CI: 1.32 to 8.71). CONCLUSION Higher gestational age and contraceptive failure were associated with a higher prevalence of complications. This information obtained through the surveillance network can be used to improve care, particularly in women more susceptible to unfavorable outcomes.
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Affiliation(s)
- Camila Ayume Amano Cavalari
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, State University of Campinas - UNICAMP - Brazil
| | - Nelio Neves Veiga-Junior
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, State University of Campinas - UNICAMP - Brazil
| | - Beatriz Deguti Kajiura
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, State University of Campinas - UNICAMP - Brazil
| | - Caroline Eugeni
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, State University of Campinas - UNICAMP - Brazil
| | | | - Luiz Francisco Baccaro
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, State University of Campinas - UNICAMP - Brazil
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21
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Low V, Choo SN, Huang Z. Reasons for termination of pregnancy in mid-trimester: A single-centre experience. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:343-345. [PMID: 33990823 DOI: 10.47102/annals-acadmedsg.2020607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Valerie Low
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore
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22
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Lee JK, Zimrin AB, Sufrin C. Society of Family Planning clinical recommendations: Management of individuals with bleeding or thrombotic disorders undergoing abortion. Contraception 2021; 104:119-127. [PMID: 33766610 DOI: 10.1016/j.contraception.2021.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 02/06/2023]
Abstract
Individuals who have bleeding disorders, thrombophilias, a history of venous thromboembolism (VTE), or who are taking anticoagulation medication for other reasons may present for abortion. Clinicians should be aware of risk factors and histories concerning for excessive bleeding and thrombotic disorders around the time of abortion. This document will focus on how to approach abortion planning in these individuals. For first-trimester abortion, procedural abortion (sometimes called surgical abortion) is generally preferred over medical management for individuals with bleeding disorders or who are on anticoagulation. First-trimester procedural abortion in an individual on anticoagulation can generally be done without interruption of anticoagulation. The decision to interrupt anticoagulation for a second-trimester procedure should be individualized. Individuals at high risk for VTE can be offered anticoagulation post-procedure. Individuals with bleeding disorders or who are anticoagulated can safely be offered progestin intrauterine devices. Future research is needed to better assess quantitative blood loss and complications rates with abortion in these populations.
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Affiliation(s)
- Jessica K Lee
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, United States.
| | - Ann B Zimrin
- University of Maryland Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Carolyn Sufrin
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, United States
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23
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Orlowski MH, Soares WE, Kerrigan KA, Zerden ML. Management of Postabortion Complications for the Emergency Medicine Clinician. Ann Emerg Med 2020; 77:221-232. [PMID: 33341294 DOI: 10.1016/j.annemergmed.2020.09.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 09/02/2020] [Accepted: 09/08/2020] [Indexed: 02/02/2023]
Abstract
Although induced abortion is generally a safe outpatient procedure, many patients subsequently present to the emergency department, concerned about a postabortion complication. It is helpful for emergency physicians to understand the medications and procedures used in abortion care in the United States to effectively and efficiently triage and treat women presenting with potential complications from an abortion. Furthermore, because many states are experiencing increased abortion restrictions that limit access to care, emergency medicine physicians may encounter more patients presenting after self-managed abortions, which presents additional challenges. This article reviews the epidemiology and background of abortion care, including the range of symptoms and adverse effects that are within the scope of an uncomplicated procedure. This review also offers a comprehensive overview of management of abortion complications, including algorithms for more common complications and descriptions of less common but more severe adverse events. The article concludes with a recognition of the social stigma and legal regulations unique to abortion care.
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Affiliation(s)
| | - William E Soares
- University of Massachusetts Medical School at Baystate Medical Center, Springfield, MA
| | - Kathleen A Kerrigan
- University of Massachusetts Medical School at Baystate Medical Center, Springfield, MA
| | - Matthew L Zerden
- Planned Parenthood South Atlantic, Chapel Hill, and WakeMed Health & Hospitals, Raleigh, NC
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24
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A randomized controlled trial of methylergonovine prophylaxis after dilation and evacuation abortion. Contraception 2020; 103:116-120. [PMID: 33075332 DOI: 10.1016/j.contraception.2020.10.009] [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: 02/06/2020] [Revised: 10/06/2020] [Accepted: 10/08/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate the efficacy of intramuscular methylergonovine maleate as prophylaxis against excessive bleeding when given after dilation and evacuation (D&E) at 20-24 weeks. STUDY DESIGN We performed a randomized, double-blinded, placebo-controlled trial in patients without excessive bleeding requiring intervention after D&E completion. We administered study treatment within one minute of the end of the procedure. We primarily compared outcomes using a composite of indicators of excessive post-procedure blood loss (post-procedure measured blood loss exceeding 125 mL, uterine massage or compression for at least two minutes, administration of additional uterotonic medication, intrauterine balloon tamponade, uterine re-aspiration, blood transfusion, uterine artery embolization, hospital admission for bleeding, or major surgery). Secondary outcomes included individual indicator occurrences, satisfaction, and side effects. RESULTS From March 3, 2015 to March 31, 2017, we randomized 284 participants (n = 140 methylergonovine, n = 144 placebo), five before we registered the trial with clinicaltrials.gov. Baseline characteristics were similar between groups. The composite outcome occurred in 78 (56%) methylergonovine and 75 (52%) placebo participants (p = 0.5). Methylergonovine recipients required more intrauterine balloon use (n = 20 [14%]) versus placebo (n = 10 [7%]), p = 0.04. We also observed a non-significant trend towards more uterotonic administration (n = 56 [40%] versus n = 43 [30%], p = 0.07) and hospital admissions for bleeding (n = 4 [3%] versus n = 0, p = 0.06) in the methylergonovine group compared to placebo. CONCLUSION We observed no improvement in the composite outcome for excessive bleeding with prophylactic post-procedure methylergonovine. In addition, individual excessive bleeding outcomes occurred more frequently in the methylergonovine group, potentially indicating harm with its prophylactic use after D&E. IMPLICATIONS When administered prophylactically immediately after dilation and evacuation abortion at 20-24 weeks, methylergonovine increases uterine bleeding. Given the lack of data for effectiveness as a prophylactic agent and our findings indicating harm, we do not recommend its use for post-operative prophylaxis.
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Storey A, White K, Treder K, Woodhams E, Bell S, Cannon R. First-Trimester Abortion Complications: Simulation Cases for OB/GYN Residents in Sepsis and Hemorrhage. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2020; 16:10995. [PMID: 33094159 PMCID: PMC7566226 DOI: 10.15766/mep_2374-8265.10995] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 05/19/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Serious complications associated with first-trimester abortions are rare. The US mortality rate for these procedures is 0.7 per 100,000, primarily due to infection and hemorrhage. While complications are unlikely to arise during training, residents must be prepared to manage them in practice. To address this, we developed a 2-hour simulation-based abortion complication curriculum for OB/GYN resident learners. METHODS OB/GYN residents participated in three sessions: a case-based didactic reviewing institutional aspiration abortion practice and preop preparation; an in-vivo aspiration abortion hemorrhage simulation; and an interdepartmental postabortal sepsis simulation. Participants completed surveys before and after their participation that evaluated clinical knowledge, and self-rated competence in, and preparedness for, managing first-trimester abortion complications. RESULTS Resident learners (N = 26) represented all four classes of OB/GYN residents. Residents initially showed stronger clinical knowledge in managing postabortal hemorrhage than sepsis (90% vs. 62%, p < .001). Clinical knowledge improved following the sepsis simulation (62% to 91%, p < .001), and remained strong but unchanged after the hemorrhage simulation (90% to 87%, p = .3). Resident self-assessments of competence and preparedness were significantly improved after both the hemorrhage (p = .006) and sepsis (p = .002) simulations. Learners reported that the simulation increased their level of comfort in managing these complications in their future practice. DISCUSSION Postabortal hemorrhage and sepsis simulations increased OB/GYN residents' knowledge, comfort, and preparedness for managing rare complications of first-trimester abortions. In-vivo simulation and interdepartmental collaboration were novel aspects of these simulations that may facilitate increased preparedness and management skills.
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Affiliation(s)
- Armide Storey
- Fourth-Year Medical Student, Boston University School of Medicine
| | - Katharine White
- Associate Professor, Obstetrics and Gynecology, Boston University School of Medicine
| | - Kelly Treder
- Instructor, Obstetrics and Gynecology, Boston University School of Medicine
| | - Elisabeth Woodhams
- Assistant Professor, Obstetrics and Gynecology, Boston University School of Medicine
| | - Shannon Bell
- Assistant Professor, Obstetrics and Gynecology, Boston University School of Medicine
| | - Rachel Cannon
- Assistant Professor, Obstetrics and Gynecology, Boston University School of Medicine
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Budathoki S, Mali P, Khadka R, Rajbhandari B. Safe Abortion among Underprivileged Group Married Women of Low Resource Country: A Descriptive Cross-sectional Study. ACTA ACUST UNITED AC 2020; 58:672-676. [PMID: 33068089 PMCID: PMC7580325 DOI: 10.31729/jnma.5298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Indexed: 11/25/2022]
Abstract
Introduction: Unsafe Abortion is one of the leading causes of maternal death. The unhygienic and dangerous practice has been encountered in various geographical areas of Nepal. Despite its legalization, many women are still being not concerned and well informed regarding safe abortion and become victims of it. The main aim of this study was to assess the knowledge and practice regarding safe abortion among married women of reproductive (14 to 49) years of an underprivileged group of low resource country, Nepal. Methods: A descriptive cross-sectional study design was done in Rajbanshi community of Jhapa District. Data collection was done after taking ethical approval. Study population was selected conveniently. Data was collected by using a semi-structured questionnaire via face to face interviews among 420 married women of reproductive (14-49) years. All the extracted data were entered and analyzed using Statistical Package for the Social Services version 20. Descriptive analysis was done and presented using frequency and percentage. Results: Out of 420 respondents, 388 respondents (92.4%) found to have poor knowledge, regarding safe abortion. Likewise, only 44 respondents (10.05%) had practiced abortion, of which only 2 respondents (0.05%) had an unsafe abortion and 42 respondents (10%) had practiced safe abortion. Conclusions: Practices of unsafe abortion were prevalent. Respondents with poor knowledge were found to have done abortion. In this context, it can be concluded that knowledge regarding safe abortion can be increased by educating and providing awareness to the people of society.
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Affiliation(s)
| | - Prajita Mali
- Department of Public Health, Om Health Campus, Kathmandu, Nepal
| | - Rakshya Khadka
- Centre for Mental Health and Counselling Service-Nepal, Nepal
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Henkel A, Lerma K, Blumenthal PD, Shaw KA. Evaluation of shorter mifepristone to misoprostol intervals for second trimester medical abortion: a retrospective cohort study. Contraception 2020; 102:327-331. [PMID: 32592800 DOI: 10.1016/j.contraception.2020.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess shorter mifepristone-misoprostol intervals compared to current guidelines for second trimester medical abortion on total abortion time (mifepristone to fetal expulsion) and induction time (first misoprostol to fetal expulsion). METHODS This retrospective cohort study included women who elected for a second trimester medical abortion with mifepristone and misoprostol at an academic tertiary medical center in the United States from January 2008 to June 2018. We abstracted times of mifepristone administration, first dose of misoprostol, and fetal expulsion from the medical record. We assessed outcomes based on the shorter intervals <12 h and 12 to 24 h compared to the guideline mifepristone-misoprostol interval (24-48 h). RESULTS The study population included eighty-nine women, 47, 28, and 14 women in the <12 h, 12 24 h, guideline (24-48 h) groups, respectively. The cohort had a median gestational age of 220/7 weeks (range: 150/7-270/7) and parity of 1 (range: 0-5) with no differences observed between groups. Total abortion times were 20.7 h (range: 3.7-46.9), 30.6 h (16.7-48.0), and 42.8 h (32.7-62.6), respectively (p < 0.001). Induction times were 12.9 h (range: 1.2-36.6), 11.7 h (2.0-35.2), and 9.3 h (5.3-16.5), respectively. Fetal expulsion within 12 h of first misoprostol dose occurred in 22 (47%), 14 (50%), and 9 (64%), respectively (p = 0.52). CONCLUSIONS Shorter mifepristone-misoprostol intervals (less than 24 h) significantly decrease the total abortion time while maintaining a clinically similar induction time. IMPLICATIONS Shortening the mifepristone-misoprostol interval in second trimester medical abortion significantly decreases the total abortion time which may be preferable to some women or health systems.
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Affiliation(s)
- Andrea Henkel
- Division of Family Planning Services & Research, Department of Obstetrics & Gynecology, Stanford University, Stanford, CA, USA.
| | - Klaira Lerma
- Division of Family Planning Services & Research, Department of Obstetrics & Gynecology, Stanford University, Stanford, CA, USA
| | - Paul D Blumenthal
- Division of Family Planning Services & Research, Department of Obstetrics & Gynecology, Stanford University, Stanford, CA, USA
| | - Kate A Shaw
- Division of Family Planning Services & Research, Department of Obstetrics & Gynecology, Stanford University, Stanford, CA, USA
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Disseminated Intravascular Coagulation and Hemorrhage After Dilation and Evacuation Abortion for Fetal Death. Obstet Gynecol 2020; 134:708-713. [PMID: 31503145 DOI: 10.1097/aog.0000000000003460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the association between fetal death and risk of hemorrhage and disseminated intravascular coagulation (DIC) among women undergoing dilation and evacuation (D&E) procedures. METHODS We conducted a retrospective cohort study of all D&Es at one academic abortion clinic in San Francisco between 2009 and 2013. We abstracted data on fetal death status, demographic characteristics, and complications including hemorrhage and DIC. We examined the risk of hemorrhage and DIC among women with fetal death compared with those without. We conducted unadjusted and adjusted analyses for the outcomes of hemorrhage, DIC, and any complication. RESULTS Among 92 cases of D&E for fetal death and 4,428 cases of D&E for other reasons, hemorrhage occurred in 10% and 7%, respectively (P=.28), and DIC occurred in 2.0% and 0.2% of the fetal death and nonfetal death cohorts (P<.001). In adjusted analysis, fetal death was associated with 2.9 times higher odds of hemorrhage (95% CI 1.4-6.0). In an unadjusted analysis, fetal death was associated with 12.3 times higher odds of DIC (95% CI 2.6-58.6) and 3.0 times higher odds of any complication (95% CI 1.6-5.9). CONCLUSION Women undergoing D&E for fetal death are far more likely to experience DIC and hemorrhage than are women without fetal death, yet the absolute risk is low (2%). Although D&E providers should be prepared for DIC and hemorrhage, we do not recommend any specific preoperative preparation because the vast majority of D&E abortions for fetal death are uncomplicated.
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Affiliation(s)
- Lisa H Harris
- From the Department of Obstetrics and Gynecology and the Department of Women's Studies, University of Michigan, Ann Arbor (L.H.H.); and the Department of Obstetrics, Gynecology, and Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), and the Bixby Center for Global Reproductive Health, University of California, San Francisco, San Francisco (D.G.)
| | - Daniel Grossman
- From the Department of Obstetrics and Gynecology and the Department of Women's Studies, University of Michigan, Ann Arbor (L.H.H.); and the Department of Obstetrics, Gynecology, and Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), and the Bixby Center for Global Reproductive Health, University of California, San Francisco, San Francisco (D.G.)
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Maternal and procedural factors associated with estimated blood loss in second trimester surgical uterine evacuation: a retrospective cohort analysis. Int J Obstet Anesth 2020; 43:65-71. [PMID: 32216983 DOI: 10.1016/j.ijoa.2020.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 02/06/2020] [Accepted: 03/01/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Prior studies examining bleeding with uterine evacuation have focused on high-volume centers performing over 1100 procedures annually. The aim of this study was to examine associations between blood loss and patient and procedural characteristics in a center performing fewer than 50 procedures annually. METHODS This retrospective cohort study, with institutional review board approval, utilized procedural codes to identify patients undergoing uterine evacuation procedures between 14 weeks' and 24 weeks' gestational age across a 50-month period. The primary outcome was estimated blood loss; secondary outcomes were hemorrhage, transfusion and hospital re-admission. Associations between blood loss and other variables were examined using linear regression models. RESULTS Charts of 161 women met inclusion criteria. Median estimated blood loss was 400 mL (IQR 300 mL) with 37% of patients having blood loss of ≥500 mL. In univariate analyses, increased blood loss was associated with later gestational age (P <0.001) and pregnancy termination (P <0.001). In a multiple linear regression model, both remained significant. Each one-week increase in gestational age was associated with a 7.1% mean increase in estimated blood loss (95% CI 2.47% to 11.9%; P=0.003). Patients whose uterine evacuation was indicated for pregnancy termination had an 80.6% increase in blood loss compared with those with pre-operative fetal demise (95% CI 37.5% to 137.2%; P <0.001). Rates of peri-operative transfusion and re-admission for bleeding were <4%. CONCLUSION While blood loss may be greater in low volume centers, our transfusion and re-admission rates were low following second trimester uterine evacuation.
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Effects of Prophylactic Oxytocin on Bleeding Outcomes in Women Undergoing Dilation and Evacuation: A Randomized Controlled Trial. Obstet Gynecol 2019; 133:484-491. [PMID: 30741801 DOI: 10.1097/aog.0000000000003104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate whether routine use of intravenous oxytocin decreases the frequency of interventions to control excess blood loss during dilation and evacuation (D&E). METHODS In this multisite, randomized, double-blind, placebo-controlled trial, women undergoing D&E at 18-24 weeks of gestation received 30 units of oxytocin in 500 mL of intravenous fluid or 500 mL of intravenous fluid alone initiated on speculum placement. The primary outcome was the frequency of interventions to control excess bleeding. A sample size of 75 patients per group was needed to detect a 15% decrease in intervention from 20% to 5% with 80% power and two-sided alpha 0.05. Secondary outcomes included measured blood loss, complications, procedure duration, postoperative pain, and patient satisfaction. RESULTS From November 2014 to February 2018, we screened 337 women and randomized 160 to receive prophylactic oxytocin (n=82) or placebo (n=78). Demographic characteristics were similar between groups. The frequency of interventions for bleeding, our primary outcome, was 7.3% in the oxytocin group vs 16.7% in the placebo group, difference of 9.4% (95% CI -21.0% to 1.9%). Interventions primarily included uterine massage and uterotonic administration. Among our secondary outcomes, median measured blood loss was lower in the oxytocin group at 152 (interquartile range 98-235) mL vs 317 (interquartile range 168-464) mL (95% CI 71.6-181.5). Frequency of hemorrhage, defined as blood loss of 500 mL or more and 1,000 mL or more, was lower in the oxytocin group at 3.7% vs 21.8%, difference of 18% (95% CI -29 to -6.9%) and 1.2% vs 10.3%, difference of 9.0% (95% CI -17 to -0.7%), respectively. Procedures were shorter in the oxytocin group at a median of 11.0 (interquartile range 8.0-14.0) vs 13.5 (interquartile range 10.0-19.0) minutes in the placebo group (95% CI 1.0-4.0). We found no differences in the frequency of nonhemorrhage complications, pain scores, or satisfaction scores between groups. CONCLUSION Prophylactic use of oxytocin during D&E at 18-24 weeks of gestation did not decrease the frequency of interventions to control bleeding. However, oxytocin did decrease blood loss and frequency of hemorrhage. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT02083809.
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Paris AE, Vragovic O, Sonalkar S, Finneseth M, Borgatta L. Mifepristone and misoprostol compared to osmotic dilators for cervical preparation prior to surgical abortion at 15-18 weeks' gestation: a randomised controlled non-inferiority trial. BMJ SEXUAL & REPRODUCTIVE HEALTH 2019; 46:bmjsrh-2019-200367. [PMID: 31754065 DOI: 10.1136/bmjsrh-2019-200367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 11/04/2019] [Accepted: 11/06/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Cervical preparation is recommended prior to second-trimester surgical abortion. Osmotic dilators are an effective means to prepare the cervix, but require an additional procedure and may cause discomfort. We compared cervical preparation with mifepristone and misoprostol to preparation with osmotic dilators. STUDY DESIGN A randomised, controlled, non-inferiority trial was performed to compare cervical preparation with mifepristone and misoprostol to preparation with osmotic dilators in women undergoing surgical abortion between 15 and 18 weeks gestation. The medication group (n=29) received mifepristone 200 mg orally 24 hours prior to uterine evacuation and misoprostol 400 μg buccally 2 hours before the procedure. The dilator group (n=20) underwent osmotic dilator insertion 24 hours prior to the procedure. The primary outcome was total procedure time, from insertion to removal of the speculum. Secondary outcomes included operative time (from intrauterine instrumentation to speculum removal), initial cervical dilation, nausea, pain, ease of procedure, and whether participants would choose the same modality in the future. RESULTS For mean total procedure time, medication preparation (14.0 min, 95% CI 12.0-16.1) was not inferior to dilators (14.3 min, 95% CI 11.7 to 16.8, p<0.001). Mean operative time and ease of procedure were also similar between groups. More women in the medication group than the dilator group would prefer to use the same method in the future (86% vs 30%, p=0.003). CONCLUSION Prior to surgical abortion at 15-18 weeks, use of mifepristone and misoprostol did not result in longer procedure times than overnight osmotic dilators. TRIAL REGISTRATION NUMBER NCT01462.
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Affiliation(s)
- Amy E Paris
- Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | | | - Sarita Sonalkar
- Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Molly Finneseth
- Obstetrics and Gynecology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Lynn Borgatta
- Obstetrics and Gynecology, Boston University School of Medicine, Boston, Massachusetts, USA
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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.
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Jegaden M, Scetbun E, Gaudu S, Fernandez H, Vigoureux S. A Lost Balloon-The Interest of a Systematic Ultrasonographyafter a Postabortion Hemorrhage. J Minim Invasive Gynecol 2019; 26:997-998. [PMID: 30708119 DOI: 10.1016/j.jmig.2019.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Margaux Jegaden
- Department of Obstetrics and Gynecology, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France (Drs. Jegaden, Scetbun, Gaudu, Fernandez, and Vigoureux)
| | - Elsa Scetbun
- Department of Obstetrics and Gynecology, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France (Drs. Jegaden, Scetbun, Gaudu, Fernandez, and Vigoureux)
| | - Sophie Gaudu
- Department of Obstetrics and Gynecology, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France (Drs. Jegaden, Scetbun, Gaudu, Fernandez, and Vigoureux)
| | - Herve Fernandez
- Department of Obstetrics and Gynecology, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France (Drs. Jegaden, Scetbun, Gaudu, Fernandez, and Vigoureux); Faculté de Médecine Paris-Sud, Université Paris-Sud, Le Kremlin-Bicêtre, France (Drs. Fernandez and Vigoureux); CESP Centre for Research in Epidemiology and Population Health, U1018, Reproduction and Child Development, Institut national de la santé et de la recherche médicale, Villejuif, France (Drs. Fernandez and Vigoureux)
| | - Solène Vigoureux
- Department of Obstetrics and Gynecology, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France (Drs. Jegaden, Scetbun, Gaudu, Fernandez, and Vigoureux); Faculté de Médecine Paris-Sud, Université Paris-Sud, Le Kremlin-Bicêtre, France (Drs. Fernandez and Vigoureux); CESP Centre for Research in Epidemiology and Population Health, U1018, Reproduction and Child Development, Institut national de la santé et de la recherche médicale, Villejuif, France (Drs. Fernandez and Vigoureux)..
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Intraoperative Blood Loss during Induced Abortion: A Comparison of Anesthetics. Anesthesiol Res Pract 2019; 2018:4051896. [PMID: 30631348 PMCID: PMC6305036 DOI: 10.1155/2018/4051896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/10/2018] [Indexed: 11/17/2022] Open
Abstract
Objective To determine whether there is a difference in intraoperative bleeding with inhalational versus noninhalational anesthetic agents for patients undergoing suction dilatation and curettage for first-trimester induced abortion. Methods This is an IRB-approved retrospective chart review of the electronic medical records of patients undergoing induced abortion at gestational ages between 5 0/7 and 14 0/7 weeks of pregnancy at the New York City Health + Hospitals/Metropolitan. The records of 138 patients who underwent suction dilatation and curettage for induced abortion between June 2012 and June 2014 were reviewed for an association between anesthetic technique and intraoperative hemorrhage. Twenty patients received inhalational anesthetic agents, while 118 received intravenous anesthetics. Blood loss was estimated by the operating gynecologists. Results The mean intraoperative blood loss for inhalational anesthetics (113.6 ml) was significantly higher than with noninhalational agents (40.2 ml) (p=0.007). Age, body mass index, and gestational age were not statistically different between the groups; the number of methylergonovine doses at induced abortion trended higher with inhalation anesthetics. Conclusions The difference in blood loss between the two types of anesthetic techniques was statistically significant. These findings may be important for patients with significant anemia or at an increased risk of bleeding, such as those with unrecognized coagulopathies.
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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]
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White KO, Jones HE, Shorter J, Norman WV, Guilbert E, Lichtenberg ES, Paul M. Second-trimester surgical abortion practices in the United States. Contraception 2018; 98:S0010-7824(18)30140-9. [PMID: 29665357 DOI: 10.1016/j.contraception.2018.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 03/31/2018] [Accepted: 04/04/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To assess whether second-trimester surgical abortion practices of U.S. providers agree with evidence-based policy guidelines. STUDY DESIGN We conducted a cross-sectional survey of abortion facilities in the U.S. identified via publicly available resources and professional networks from June through December 2013. RESULTS Of 703 identified facilities, 383 (54%) participated, including 172 clinicians providing second-trimester surgical abortions (dilation and evacuations [D&Es]). The majority of clinicians were obstetrician-gynecologists (87%), female (67%), and less than 50 years old (62%). Most clinicians (93%) ever use misoprostol as a cervical preparation agent, including in the setting of a uterine scar (87%). Some clinicians refer to a hospital-based provider if the patient has a placenta previa and a history of cesarean section (31%) or a complete previa alone (17%). Many clinicians have weight or body mass index restrictions for cases performed under iv moderate sedation (32/97, 33%) or deep sedation (23/50, 46%). Most clinicians (69%) who report performing D&Es at 18 weeks last menstrual period or greater do not routinely induce fetal demise preoperatively. Clinicians employ routine intraoperative ultrasound (79%) more commonly than routine postoperative ultrasound (47%), with no difference by years of provider experience. Most clinicians routinely use prophylactic uterotonic agents, most often postoperatively. Most clinicians (80%) routinely give perioperative antibiotics, most often doxycycline (75%). CONCLUSION Overall, the second-trimester surgical abortion practices revealed in our survey agree with professional evidence-based policy guidelines. Wider variability was reported for practices lacking a strong evidence base. IMPLICATIONS In this third cross-sectional survey of U.S. abortion practices (prior 1997 and 2002), second-trimester surgical abortion providers are younger than before, reflecting an improvement in the "graying" of the abortion provider workforce. Facility restrictions on gestational age along with hospital restrictions on referrals pose barriers to outpatient abortion access.
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Affiliation(s)
- Katharine O White
- Boston Medical Center/Boston University, 850 Harrison Avenue, Dowling 4402, Boston, MA, 02118, USA.
| | - Heidi E Jones
- City University of New York Graduate School of Public Health & Health Policy, 2180 Third Avenue, New York, NY 10035, USA.
| | - Jade Shorter
- Boston Medical Center/Boston University, 850 Harrison Avenue, Dowling 4402, Boston, MA, 02118, USA.
| | - Wendy V Norman
- University of British Columbia, 320-5950 University Blvd, Vancouver, Canada, V6T 1Z3.
| | - Edith Guilbert
- Institut National de Santé Publique du Québec, 945, avenue Wolfe, Québec, Canada, G1V 5B3.
| | - E Steve Lichtenberg
- Family Planning Medical Associates Medical Group, Limited, 659 West Washington Boulevard, Chicago, IL 60661, USA.
| | - Maureen Paul
- Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.
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Menderes G, Leon-Martinez D, Azodi M. Laparoscopic Ligation of Uterine Vasculature for Fertility-Sparing Management of Postabortal Hemorrhage. J Minim Invasive Gynecol 2018; 26:36-37. [PMID: 29609031 DOI: 10.1016/j.jmig.2018.03.020] [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: 12/30/2017] [Revised: 03/21/2018] [Accepted: 03/27/2018] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE To present a surgical video in which bilateral uterine vasculature was ligated laparoscopically in order to preserve the uterus in a patient with postabortal hemorrhage. DESIGN A case report (Canadian Task Force classification III). SETTING A tertiary referral center in New Haven, CT. INTERVENTIONS This is a step-by-step demonstration of laparoscopic ligation of the uterine vasculature in a patient with postabortal hemorrhage. The patient was a 33-year-old Para 4014 woman who presented with postabortal hemorrhage after she underwent an urgent dilation and evacuation for the management of symptomatic placenta accreta at 19 weeks of pregnancy. The patient underwent a physical examination when she presented to the emergency department with postabortal hemorrhage. She was hemodynamically stable, and the examination was negative for cervical or vaginal lacerations. Coagulation studies were negative for any coagulopathy. A pelvic ultrasound did not show any retained products of conception. As per the Society of Family Planning guidelines, uterine massage was performed, and uterotonics (i.e., methylergonovine maleate 0.2 mg intramuscularly and misoprostol 1000 mg per rectum) were given [1]. The postabortal hemorrhage persisted despite medical therapy with an approximate blood loss of 600 mL over 2 hours. An intrauterine tamponade balloon was placed, and the patient then underwent a uterine angiogram and bilateral uterine artery embolization secondary to continued vaginal bleeding despite medical management. She was closely monitored and noted to have another 500 mL of blood loss over 2 hours after completion of uterine artery embolization. At this point, she was resuscitated with 2 U red blood cells because she developed symptoms of hemodynamic instability. Her hematocrit was increased suboptimally after transfusion with stabilization of her vitals. The patient was then counseled on her surgical options because she had failed medical management, intrauterine balloon tamponade, and uterine artery embolization. She stated a strong desire to preserve her uterus. Given her overall hemodynamic stability, laparoscopic ligation of the uterine vessels was proposed, which she agreed on [2]. Risks of the laparoscopic approach were explained to the patient, which included injury to the uterus, ureters, blood vessels, and nerves as well as the possibility of conversion to laparotomy. The surgery started with exploration of the peritoneal cavity. Her uterus was noted to be significantly enlarged with many engorged vessels. In order to decrease the risk of uterine perforation in this bulky and highly vascular uterus, the surgeon decided not to place a uterine manipulator. The retroperitoneum was entered at the right pelvic sidewall. Pararectal and paravesical spaces were then developed. Ureterolysis was performed in order to free its peritoneal and uterine artery attachments. The uterine artery was skeletonized cephalad to the hypogastric bifurcation and was ligated with 5-mm vascular clips. The attention was then turned to the ovarian vessels at the cornu of the uterus. Peritoneal avascular windows were created inferior and superior to the vessels. The blood supply was then ligated with an absorbable suture, and the ligature was secured using the extracorporeal knot tying technique. The same steps were repeated on the left pelvic sidewall. The procedure was completed once excellent hemostasis was assured. Besides the technical steps of the procedure, pelvic anatomic landmarks have also been emphasized in this video for educational purposes. MEASUREMENTS AND MAIN RESULTS Laparoscopic ligation of the uterine vasculature was performed without any complications. The operative time was 65 minutes, and blood loss was minimal. The patient had an uneventful postoperative course and was discharged home the day after her laparoscopic surgery. CONCLUSION The uterus was preserved with this minimally invasive approach for the management of postabortal hemorrhage. Laparoscopic ligation of the uterine vessels should be considered in hemodynamically stable patients who desire future fertility when managing postabortal hemorrhage.
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Affiliation(s)
- Gulden Menderes
- Department of Obstetrics and Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut.
| | - Daisy Leon-Martinez
- Department of Obstetrics and Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Masoud Azodi
- Department of Obstetrics and Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
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Whitehouse K, Fontanilla T, Kim L, Tschann M, Soon R, Salcedo J, Kaneshiro B. Use of medications to decrease bleeding during surgical abortion: a survey of abortion providers' practices in the United States. Contraception 2018; 97:500-503. [PMID: 29490288 DOI: 10.1016/j.contraception.2018.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 02/21/2018] [Accepted: 02/21/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Our objective was to document current practices of abortion providers on the use of medications to decrease bleeding during surgical abortion. STUDY DESIGN We emailed surveys to 336 abortion providers through a professional listserv to elicit information on their use of medications to prevent and treat bleeding during first- and second-trimester surgical abortion. RESULTS One hundred sixty-eight (50%) providers responded to our survey. The majority were obstetrician-gynecologists (83%) working in an academic practice (66%). Most completed a fellowship in family planning (87%) and currently perform abortions up to 22 or 24weeks of gestation (63%). Seventy-two percent routinely used prophylactic medications for bleeding. Providers who routinely used medications to prevent bleeding most commonly chose vasopressin (83%). Providers preferred methylergonovine as a treatment for excessive bleeding in the second trimester, followed by misoprostol. CONCLUSION We found that most providers routinely use medications to prevent bleeding and use several different regimens to treat bleeding during abortion. IMPLICATIONS We found that surgical abortion providers use a range of medications to prevent and treat hemorrhage at the time of surgical abortion. Scant evidence is available to guide abortion providers on the use of medications to decrease hemorrhage during surgical abortion. To provide evidence-based recommendations for the prevention and treatment of clinically significant bleeding, researchers should target the most commonly used interventions.
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Affiliation(s)
- Katherine Whitehouse
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou St., Ste. 824, Honolulu, HI 96826, USA.
| | - Tiana Fontanilla
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou St., Ste. 824, Honolulu, HI 96826, USA
| | - Leslie Kim
- University of Hawaii, John A. Burns School of Medicine, 651 Ilalo St., Honolulu, HI 96813, USA
| | - Mary Tschann
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou St., Ste. 824, Honolulu, HI 96826, USA
| | - Reni Soon
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou St., Ste. 824, Honolulu, HI 96826, USA
| | - Jennifer Salcedo
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou St., Ste. 824, Honolulu, HI 96826, USA
| | - Bliss Kaneshiro
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou St., Ste. 824, Honolulu, HI 96826, USA
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Shim JY, Patel A. Therapeutic anticoagulation for pulmonary embolism during first-trimester surgical abortion: two case reports. Contraception 2018; 97:565-566. [PMID: 29428851 DOI: 10.1016/j.contraception.2018.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 01/27/2018] [Accepted: 01/30/2018] [Indexed: 11/30/2022]
Abstract
We report two patients with bilateral pulmonary embolism who presented to our county hospital reproductive health services clinic. Both patients underwent an uncomplicated first-trimester aspiration abortion while on therapeutic unfractionated heparin therapy. Anticoagulation therapy may be modified to safely perform first-trimester surgical termination without significant blood loss.
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Affiliation(s)
- Jessica Y Shim
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Division of Family Planning, Obstetrics and Gynecology, The John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA.
| | - Ashlesha Patel
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Division of Family Planning, Obstetrics and Gynecology, The John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
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Estimated versus measured blood loss during dilation and evacuation: an observational study. Contraception 2018; 97:451-455. [PMID: 29410259 DOI: 10.1016/j.contraception.2018.01.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 01/16/2018] [Accepted: 01/16/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To compare estimated versus measured blood loss at the time of dilation and evacuation (D&E). STUDY DESIGN We measured blood loss for all D&E procedures between 16 and 24 weeks at one abortion clinic over 9 months. We weighed all blood-containing items and measured blood captured in the D&E tray. Providers recorded estimated blood loss before weighing or measuring blood. We compared median measured blood loss (MBL) and estimated blood loss (EBL) for each gestational week. RESULTS We measured blood loss in 371 of the 534 D&Es in the study period; we excluded 163 procedures because of failure to measure blood loss or contamination with amniotic fluid. Included and excluded procedures had similar median EBLs. Median EBL differed significantly from MBL for each week gestation from 16 to 24 weeks (p≤.001 for all comparisons); MBL was approximately twice as high as EBL for each gestational week. EBL and MBL increased with increasing gestation, as did the difference between EBL and MBL. CONCLUSION Providers consistently and significantly underestimate blood loss at the time of D&E. D&E providers may want to consider using a new heuristic for estimating blood loss. IMPLICATIONS Providers significantly underestimate blood loss at the time of D&E. Future research should confirm these findings (particularly at 22-24 weeks gestation), evaluate the efficacy of interventions to improve estimations of blood loss, and determine best practices for decreasing blood loss.
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Blood loss at the time of dilation and evacuation at 16 to 22 weeks of gestation in women using low molecular weight heparin: a case series. Contraception 2018; 97:54-56. [DOI: 10.1016/j.contraception.2017.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 09/01/2017] [Accepted: 09/06/2017] [Indexed: 11/21/2022]
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Iraha Y, Okada M, Toguchi M, Azama K, Mekaru K, Kinjo T, Kudaka W, Aoki Y, Aoyama H, Matsuzaki A, Murayama S. Multimodality imaging in secondary postpartum or postabortion hemorrhage: retained products of conception and related conditions. Jpn J Radiol 2017; 36:12-22. [PMID: 29052024 DOI: 10.1007/s11604-017-0687-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 09/27/2017] [Indexed: 12/18/2022]
Abstract
Secondary postpartum hemorrhage (PPH) and postabortion hemorrhage are rare complications. Retained products of conception (RPOC) is among the most common causes of both secondary PPH and postabortion hemorrhage. Other less common causes of secondary PPH are uterine vascular abnormalities such as arteriovenous malformations and pseudoaneurysms. These are usually related to a history of a procedure such as dilation and curettage or cesarean delivery. Subinvolution of the placental site is an idiopathic cause of secondary PPH; this condition may be underrecognized and therefore could have a higher incidence than currently reported. Gestational trophoblastic disease is rare but commonly presents as secondary PPH and resembles RPOC in radiologic appearance. The first-line imaging modality for secondary PPH is ultrasound, but computed tomography and magnetic resonance imaging may be used if the ultrasound findings are indeterminate. Angiography is an important tool for the definitive diagnosis of uterine vascular abnormalities. Appropriate management requires radiologists to be familiar with the multimodality imaging features of secondary PPH or postabortion hemorrhage.
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Affiliation(s)
- Yuko Iraha
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan.
| | - Masahiro Okada
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Masafumi Toguchi
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Kimei Azama
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Keiko Mekaru
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Tadatsugu Kinjo
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Wataru Kudaka
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Yoichi Aoki
- Department of Obstetrics and Gynecology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Hajime Aoyama
- Department of Pathology and Oncology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Akiko Matsuzaki
- Department of Pathology and Oncology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
| | - Sadayuki Murayama
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan
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Juusela AL, Gimovsky ML. Intraoperative Hemorrhage Requiring Emergent Hysterectomy: Failed Conservative Management of a Cervical Placenta Accreta. J Gynecol Surg 2017. [DOI: 10.1089/gyn.2017.0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Taylor D, Upadhyay UD, Fjerstad M, Battistelli MF, Weitz TA, Paul ME. Standardizing the classification of abortion incidents: the Procedural Abortion Incident Reporting and Surveillance (PAIRS) Framework. Contraception 2017; 96:1-13. [PMID: 28578150 DOI: 10.1016/j.contraception.2017.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 04/30/2017] [Accepted: 05/14/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To develop and validate standardized criteria for assessing abortion-related incidents (adverse events, morbidities, near misses) for first-trimester aspiration abortion procedures and to demonstrate the utility of a standardized framework [the Procedural Abortion Incident Reporting & Surveillance (PAIRS) Framework] for estimating serious abortion-related adverse events. STUDY DESIGN As part of a California-based study of early aspiration abortion provision conducted between 2007 and 2013, we developed and validated a standardized framework for defining and monitoring first-trimester (≤14weeks) aspiration abortion morbidity and adverse events using multiple methods: a literature review, framework criteria testing with empirical data, repeated expert reviews and data-based revisions to the framework. RESULTS The final framework distinguishes incidents resulting from procedural abortion care (adverse events) from morbidity related to pregnancy, the abortion process and other nonabortion related conditions. It further classifies incidents by diagnosis (confirmatory data, etiology, risk factors), management (treatment type and location), timing (immediate or delayed), seriousness (minor or major) and outcome. Empirical validation of the framework using data from 19,673 women receiving aspiration abortions revealed almost an equal proportion of total adverse events (n=205, 1.04%) and total abortion- or pregnancy-related morbidity (n=194, 0.99%). The majority of adverse events were due to retained products of conception (0.37%), failed attempted abortion (0.15%) and postabortion infection (0.17%). Serious or major adverse events were rare (n=11, 0.06%). CONCLUSIONS Distinguishing morbidity diagnoses from adverse events using a standardized, empirically tested framework confirms the very low frequency of serious adverse events related to clinic-based abortion care. IMPLICATIONS The PAIRS Framework provides a useful set of tools to systematically classify and monitor abortion-related incidents for first-trimester aspiration abortion procedures. Standardization will assist healthcare providers, researchers and policymakers to anticipate morbidity and prevent abortion adverse events, improve care metrics and enhance abortion quality.
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Affiliation(s)
- Diana Taylor
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, and School of Nursing, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612.
| | - Ushma D Upadhyay
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics Gynecology and Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612
| | - Mary Fjerstad
- National Abortion Federation, 1090 Vermont Avenue NW #1000, Washington, DC 20005
| | - Molly F Battistelli
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics Gynecology and Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612
| | - Tracy A Weitz
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics Gynecology and Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612
| | - Maureen E Paul
- Beth Israel Deaconess Medical Center, Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215
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Whitehouse K, Tschann M, Davis J, Soon R, Salcedo J, Friedlander E, Kaneshiro B. Association between prophylactic oxytocin use during dilation and evacuation and estimated blood loss. Contraception 2017; 96:19-24. [PMID: 28483553 DOI: 10.1016/j.contraception.2017.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/24/2017] [Accepted: 04/27/2017] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Some providers use oxytocin during dilation and evacuation (D&E) to prevent or treat hemorrhage, although evidence to support this is scarce. We sought to describe the association between prophylactic oxytocin use, estimated blood loss (EBL), and surgical outcomes during D&E. STUDY DESIGN We performed a chart review of 730 women at 14 to 26 weeks' gestation who had a D&E at our institution between May 2010 and May 2014 to assess the association between prophylactic oxytocin use and EBL. We determined whether sociodemographic and health-related factors were associated with excessive blood loss (EBL≥250 mL) and whether oxytocin use was associated with complications, including hemorrhage (i.e., EBL≥500 mL or interventions for bleeding). We performed univariate analyses and multivariable regression models to evaluate the relationship between health-related factors and EBL≥250 mL. RESULTS Providers used prophylactic oxytocin in 59.9% of procedures. Asian (p=.005 and Native Hawaiian/Pacific Islander (p=.005) race, nulliparity (p=.007) and higher gestational age (p<.001) were associated with prophylactic oxytocin use. We found no difference in mean EBL (116.2±105.5 mL versus 130.7±125.5 mL, p=.09), EBL≥250 mL (31.4% vs. 68.6%, p=.15) or complications (6.1% vs. 7.1%, p=.73) including hemorrhage (1.4% vs. 5.3%, p=.14) between those who did not receive prophylactic oxytocin and those who did. No transfusions occurred in either group. In multivariable regression modeling, the adjusted OR for excessive blood loss was 0.42 (95% confidence interval 0.16-1.07) with prophylactic oxytocin use. CONCLUSIONS Prophylactic oxytocin use during D&E was not associated with hemorrhage or transfusion in our population. IMPLICATIONS Routine use of interventions for bleeding, such as intravenous oxytocin, should be based on scientific evidence or not performed. Findings from our study provide information on how oxytocin use is associated with blood loss during D&E.
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Affiliation(s)
- Katherine Whitehouse
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou Street, Ste 824, Honolulu, HI 96826
| | - Mary Tschann
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou Street, Ste 824, Honolulu, HI 96826
| | - James Davis
- University of Hawaii, John A. Burns School of Medicine, Department of Biostatistics & Data Management, 651 Ilalo Street, Biosciences Building, Ste 211, Honolulu, HI 96813
| | - Reni Soon
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou Street, Ste 824, Honolulu, HI 96826
| | - Jennifer Salcedo
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou Street, Ste 824, Honolulu, HI 96826
| | - EmmaKate Friedlander
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou Street, Ste 824, Honolulu, HI 96826
| | - Bliss Kaneshiro
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou Street, Ste 824, Honolulu, HI 96826.
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Kaneshiro B, Tschann M, Jensen J, Bednarek P, Texeira R, Edelman A. Blood loss at the time of surgical abortion up to 14 weeks in anticoagulated patients: a case series. Contraception 2017; 96:14-18. [PMID: 28288789 DOI: 10.1016/j.contraception.2017.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 03/03/2017] [Accepted: 03/03/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe estimated blood loss (EBL) with surgical abortion ≤14 weeks' gestation in anticoagulated patients. STUDY DESIGN We invited 170 clinicians involved in a professional listserv to report cases when they performed a surgical abortion on a patient ≤14 weeks' gestation taking an anticoagulant. Clinicians reported EBL and bleeding-related complications (need for a blood transfusion, additional surgical procedures to treat bleeding). We contacted clinicians 30 days postprocedure to capture postoperative complications. RESULTS Clinicians reported 52 cases between February 2011 and October 2013. Thirty percent of patients (16/52) stopped the anticoagulant with adequate time for the effects to abate prior to surgery (6 h for heparin, 24 h for low-molecular-weight heparin, International Normalized Ratio ≤1.7 the day prior to surgery for warfarin), while 69% (36/52) continued the anticoagulant either at therapeutic (25/36) or subtherapeutic (16/36) doses. Seventy-eight percent (28/36) of patients who continued the anticoagulant had an EBL of 50 mL or less compared to 88% (14/16) of those who stopped the anticoagulant with adequate time for its effects to abate (p=.73). Bleeding-related complications occurred in four anticoagulated patients and none of the patients who discontinued anticoagulant therapy. CONCLUSION Continuation of anticoagulation for planned surgical abortion under 84 days does not appear to be associated with heavy bleeding.
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Affiliation(s)
- Bliss Kaneshiro
- Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii John A. Burns School of Medicine, 1319 Punahou Street, Honolulu, HI 96826, USA.
| | - Mary Tschann
- Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii John A. Burns School of Medicine, 1319 Punahou Street, Honolulu, HI 96826, USA
| | - Jeffrey Jensen
- Department of Obstetrics and Gynecology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Paula Bednarek
- Department of Obstetrics and Gynecology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Ronnie Texeira
- Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii John A. Burns School of Medicine, 1319 Punahou Street, Honolulu, HI 96826, USA
| | - Alison Edelman
- Department of Obstetrics and Gynecology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
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Perriera LK, Arslan AA, Masch R. Placenta praevia and the risk of adverse outcomes during second trimester abortion: A retrospective cohort study. Aust N Z J Obstet Gynaecol 2017; 57:99-104. [DOI: 10.1111/ajo.12580] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 11/23/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Lisa K. Perriera
- Department of Obstetrics and Gynaecology; Sidney Kimmel College of Medicine at Thomas Jefferson University; Philadelphia Pennsylvania USA
| | - Alan A. Arslan
- Department of Obstetrics and Gynaecology; New York University School of Medicine; New York New York USA
| | - Rachel Masch
- Department of Obstetrics and Gynaecology; Mount Sinai Beth Israel Medical Center; New York New York USA
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Ko HK, Shin JH, Ko GY, Gwon DI, Kim JH, Han K, Lee SW. Efficacy of Prophylactic Uterine Artery Embolization before Obstetrical Procedures with High Risk for Massive Bleeding. Korean J Radiol 2017; 18:355-360. [PMID: 28246515 PMCID: PMC5313523 DOI: 10.3348/kjr.2017.18.2.355] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 10/20/2016] [Indexed: 11/15/2022] Open
Abstract
Objective To evaluate the safety and efficacy of prophylactic uterine artery embolization (UAE) before obstetrical procedures with high risk for massive bleeding. Materials and Methods A retrospective review of 29 female patients who underwent prophylactic UAE from June 2009 to February 2014 was performed. Indications for prophylactic UAE were as follows: dilatation and curettage (D&C) associated with ectopic pregnancy (cesarean scar pregnancy, n = 9; cervical pregnancy, n = 6), termination of pregnancy with abnormal placentation (placenta previa, n = 8), D&C for retained placenta with vascularity (n = 5), and D&C for suspected gestational trophoblastic disease (n = 1). Their medical records were reviewed to evaluate the safety and efficacy of UAE. Results All women received successful bilateral prophylactic UAE followed by D&C with preservation of the uterus. In all patients, UAE followed by obstetrical procedure prevented significant vaginal bleeding on gynecologic examination. There was no major complication related to UAE. Vaginal spotting continued for 3 months in three cases. Although oligomenorrhea continued for six months in one patient, normal menstruation resumed in all patients afterwards. During follow-up, four had subsequent successful natural pregnancies. Spontaneous abortion occurred in one of them during the first trimester. Conclusion Prophylactic UAE before an obstetrical procedure in patients with high risk of bleeding or symptomatic bleeding may be a safe and effective way to manage or prevent serious bleeding, especially for women who wish to preserve their fertility.
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Affiliation(s)
- Heung Kyu Ko
- Department of Radiology, Asan Medical Center, Ulsan University College of Medicine, Seoul 05505, Korea
| | - Ji Hoon Shin
- Department of Radiology, Asan Medical Center, Ulsan University College of Medicine, Seoul 05505, Korea
| | - Gi Young Ko
- Department of Radiology, Asan Medical Center, Ulsan University College of Medicine, Seoul 05505, Korea
| | - Dong Il Gwon
- Department of Radiology, Asan Medical Center, Ulsan University College of Medicine, Seoul 05505, Korea
| | - Jin Hyung Kim
- Department of Radiology, Asan Medical Center, Ulsan University College of Medicine, Seoul 05505, Korea
| | - Kichang Han
- Department of Radiology, Asan Medical Center, Ulsan University College of Medicine, Seoul 05505, Korea
| | - Shin-Wha Lee
- Department of Obstetrics and Gynecology, Asan Medical Center, Ulsan University College of Medicine, Seoul 05505, Korea
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Faucher P. [Complications of termination of pregnancy]. ACTA ACUST UNITED AC 2016; 45:1536-1551. [PMID: 27816250 DOI: 10.1016/j.jgyn.2016.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 09/20/2016] [Accepted: 09/20/2016] [Indexed: 11/15/2022]
Abstract
The legalization of abortion in France allowed to disappear almost maternal deaths caused by induced abortions. Nevertheless, the practice of abortion in a medical framework is encumbered with a number of immediate complications. Similarly, the late consequences of the practice of surgical abortion have generated an abundant literature, which it is important to analyse, both to meet the legitimate concerns of patients as to prevent any spread of false ideas under the influence of movements opposed to abortion.
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Affiliation(s)
- P Faucher
- Unité fonctionnelle d'orthogénie, hôpital Trousseau, 26, rue du Dr-Arnold-Netter, 75571 Paris cedex 12, France.
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