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Ngo LL, Mokashi M, Janiak E, Bartz D, Fortin J, Maurer R, Goldberg AB. Acute complications with same-day versus overnight cervical preparation before dilation and evacuation at 14 to 16 weeks. Contraception 2023; 117:61-66. [PMID: 36240901 DOI: 10.1016/j.contraception.2022.09.126] [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: 01/10/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Evaluate if same-day cervical preparation is associated with a clinically acceptable complication rate compared with overnight osmotic dilators for dilation and evacuation (D&E). STUDY DESIGN This retrospective, noninferiority, cohort study compared complication rates for same-day versus overnight cervical preparation with D&E between 14 and 16 weeks gestation. Cervical preparation was achieved with misoprostol, osmotic dilators, or both. Our primary outcome was the acute complication rate, defined as: hemorrhage (≥500 mL); hospitalization or hospital transfer; transfusion; or unplanned procedure occurring within 24 hours of the index procedure. Secondarily we evaluated nonmajor (re-aspiration, suture repair of cervical laceration, uterine tamponade, or emergency department only transfer) and major (transfusion, uterine artery embolization, abdominal surgery, or hospital admission) complications separately. Inverse probability of treatment weighting using the propensity score was used to perform an adjusted analysis, taking into account age, ethnicity, clinic location, insurance, gestational age, gravidity, and prior pregnancy outcomes. RESULTS We analyzed 1,319 subjects (n = 864 same-day, n = 455 overnight). Same-day cervical preparation patients were more likely to have Medicaid and a prior vaginal delivery. In both unadjusted and adjusted analyses, acute complication rates for same-day were noninferior to overnight preparation (unadjusted 0.93% vs 1.98%, difference of -1.05%, CI: -2.48% to 0.38%; adjusted difference -0.50%, CI: -1.45 to 0.44%). Only one major complication in the same-day group, a cervical laceration resulting in hemorrhage requiring transfusion, occurred in the entire sample. CONCLUSIONS In this retrospective review, same-day cervical preparation was noninferior to overnight preparation for D&E between 14 and 16 weeks gestation, both with low complication rates. IMPLICATIONS For early second trimester dilation and evacuation, same-day cervical preparation should be considered a safe alternative to overnight cervical preparation.
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Affiliation(s)
- Lynn L Ngo
- Southern California Permanente Medical Group, San Diego, CA, USA.
| | | | - Elizabeth Janiak
- Harvard Medical School, Boston, MA, USA; Brigham and Women's Hospital, Department of Obstetrics, Gynecology, and Reproductive Biology, Boston, MA, USA; Planned Parenthood League of Massachusetts, Boston, MA, USA
| | - Deborah Bartz
- Harvard Medical School, Boston, MA, USA; Brigham and Women's Hospital, Department of Obstetrics, Gynecology, and Reproductive Biology, Boston, MA, USA; Planned Parenthood League of Massachusetts, Boston, MA, USA
| | | | - Rie Maurer
- Brigham and Women's Hospital, Center for Clinical Investigation, Boston, MA, USA
| | - Alisa B Goldberg
- Harvard Medical School, Boston, MA, USA; Brigham and Women's Hospital, Department of Obstetrics, Gynecology, and Reproductive Biology, Boston, MA, USA; Planned Parenthood League of Massachusetts, Boston, MA, USA
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2
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Dzuba IG, Chandrasekaran S, Fix L, Blanchard K, King E. Pain, Side Effects, and Abortion Experience Among People Seeking Abortion Care in the Second Trimester. WOMEN'S HEALTH REPORTS 2022; 3:533-542. [PMID: 35651992 PMCID: PMC9148646 DOI: 10.1089/whr.2021.0103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 12/04/2022]
Abstract
Background: There is limited documentation about pain and side effects associated with dilation and evacuation (D&E) abortion, yet, pain and side effects are important factors that can affect a client's abortion experience. In 2016, Hope Clinic for Women, an independent abortion clinic in Illinois, altered its cervical preparation protocols before D&E to reduce the total time of the abortion process and improve the client experience. This analysis addresses the gap in data on client experience of abortion in the later second trimester by evaluating pain, side effects, and acceptability by gestational age. Methods: Abortion clients obtaining services at the clinic between March 2017 and June 2018 were eligible to participate if they had viable singleton pregnancies of 16–23.6 weeks' gestation, spoke English, and were at least 18 years old. Eligible participants completed a two-part survey about their abortion experience. Results: We found that respondents seeking abortion care at later gestations in the second trimester were more likely to report pain during their abortions. We did not find any association between side effects and gestational age. Conclusion: Although most respondents were prepared for the pain they experienced, some reported experiencing more pain than they expected, and more effective pain relief was commonly reported as a way to improve the service. More research on patient experiences of later abortion is needed, particularly on experiences of pain and options for pain management.
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Affiliation(s)
| | | | - Laura Fix
- Ibis Reproductive Health, Cambridge, Massachusetts, USA
| | | | - Erin King
- Hope Clinic for Women, Granite City, Illinois, USA
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3
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Cohen MA, Kapp N, Edelman A. Abortion Care Beyond 13 Weeks' Gestation: A Global Perspective. Clin Obstet Gynecol 2021; 64:460-474. [PMID: 34323228 DOI: 10.1097/grf.0000000000000631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The majority of abortions are performed early in pregnancy, but later abortion accounts for a large proportion of abortion-related morbidity and mortality. People who need this care are often the most vulnerable-the poor, the young, those who experience violence, and those with significant health issues. In settings with access to safe care, studies demonstrate significant declines in abortion-related morbidity and mortality. This review focuses on evidence-based practices for induced abortion beyond 13 weeks' gestation and post-abortion care in both high- and low-resource settings. We also highlight key programmatic issues to consider when expanding the gestational age for abortion services.
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Affiliation(s)
- Megan A Cohen
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
| | | | - Alison Edelman
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
- Ipas, Chapel Hill, North Carolina
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Cervical priming before surgical abortion between 14 and 24 weeks: a systematic review and meta-analyses for the National Institute for Health and Care Excellence-new clinical guidelines for England. Am J Obstet Gynecol MFM 2020; 3:100283. [PMID: 33451604 DOI: 10.1016/j.ajogmf.2020.100283] [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: 09/20/2020] [Revised: 11/11/2020] [Accepted: 11/18/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This study aimed to determine the optimal cervical priming regimen before surgical abortion between 14+0 and 24+0 weeks' gestation. DATA SOURCES Embase, MEDLINE, and the Cochrane Library were searched for publications up to February 2020. Experts were consulted for any ongoing or missed trials. STUDY ELIGIBILITY CRITERIA Randomized controlled trials, published in English after 1985, that compared (1) mifepristone, misoprostol, and osmotic dilators against each other, alone or in combination; (2) different doses of mifepristone and misoprostol; (3) different intervals between priming and abortion; or (4) different routes of administration of misoprostol were included. METHODS Risk of bias was assessed using the Cochrane Collaboration checklist for randomized controlled trials, and data were meta-analyzed in Review Manager 5.3. Dichotomous outcomes were analyzed as risk ratios using the Mantel-Haenszel method, and continuous outcomes were analyzed as mean differences using the inverse variance method. Fixed effects models were used when there was no significant heterogeneity (I2<50%), random effects models were used for moderate heterogeneity (I2≤50% and <80%), and evidence was not pooled when there was high heterogeneity (I2≥80%). Subgroup analyses were undertaken based on parity where available. The overall quality of the evidence was assessed using Grades of Recommendation Assessment, Development, and Evaluation. RESULTS A total of 15 randomized controlled trials (N=2454) were included and showed decreased difficulty of procedure and/or increased cervical dilation and decreased patient acceptability with regimens that included dilators compared with those that did not include dilators; increased preoperative expulsion of the pregnancy with sublingual misoprostol and mifepristone compared with sublingual misoprostol alone; increased difficulty of procedure with dilators and misoprostol compared with dilators and mifepristone; decreased difficulty of procedure with dilators and mifepristone compared with dilators alone; and increased cervical dilation when dilators were placed the day before abortion compared with the same day. CONCLUSION Considered alongside clinical expertise, the published data support the use of osmotic dilators, misoprostol, or mifepristone before abortion for pregnancies at 14+0 to 16+0 weeks' gestation; osmotic dilators or misoprostol for pregnancies at 16+1 to 19+0 weeks' gestation; and osmotic dilators alone or with mifepristone for pregnancies at 19+1 to 24+0 weeks' gestation. The effectiveness of pharmacologic agents alone beyond 16+0 weeks' gestation and the optimal timing of dilator placement remain important questions for future research.
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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: 29] [Impact Index Per Article: 5.8] [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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Lerma K, Blumenthal PD. Current and potential methods for second trimester abortion. Best Pract Res Clin Obstet Gynaecol 2019; 63:24-36. [PMID: 31281014 DOI: 10.1016/j.bpobgyn.2019.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 11/26/2022]
Abstract
Medical and surgical methods can both be recommended for second trimester abortion (after 12-weeks of gestational age). Induced abortion with a mifepristone and misoprostol regimen is the preferred approach; where mifepristone is not available, misoprostol alone for medical abortion is also effective. Dilation and evacuation (D&E) is the procedure of choice for surgical abortions, and adequate cervical preparation contributes significantly to safety. Availability of drugs and instruments, ability to provide pain control, provider skill and comfort, client preference, cultural considerations, and local legislation all influence the method of abortion likely to be performed in a given setting. Both surgical and modern medical methods are safe and effective when provided by a trained, experienced provider.
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Affiliation(s)
- Klaira Lerma
- Stanford University, Department of Obstetrics & Gynecology, Division of Family Planning Services & Research, Stanford, CA 94503, USA.
| | - Paul D Blumenthal
- Stanford University, Department of Obstetrics & Gynecology, Division of Family Planning Services & Research, Stanford, CA 94503, USA
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7
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Constant D, Kluge J, Harries J, Grossman D. An analysis of delays among women accessing second-trimester abortion in the public sector in South Africa. Contraception 2019; 100:209-213. [PMID: 31029655 DOI: 10.1016/j.contraception.2019.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 04/11/2019] [Accepted: 04/14/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To identify key delays and associated factors in women's pathway to second-trimester abortion that could inform strategies to increase earlier presentation. STUDY DESIGN We performed a secondary analysis using data collected from May 2012 to June 2013 as part of a randomized controlled trial among women having abortion at 13.0-20.0 weeks at a public hospital in South Africa. We used ultrasound and participant interview data to calculate 3 key intervals: (1) conception to suspicion of pregnancy, (2) suspicion to first healthcare visit for abortion, and (3) first healthcare visit to abortion procedure. We compared intervals for women at 13-15.0 weeks versus 15.1-20.0 weeks gestation at abortion using Wilcoxon rank-sum tests and tested for associations between gestational age at key events using multivariable linear regression. RESULTS Median (interquartile range[IQR]) durations for the 3 intervals among women at 13-15 weeks (n=93) compared to 15.1-20 weeks (n=63) gestation were: (1) 36 days (IQR 21-53 days) versus 62 days (36-71 days), p<.001; (2) 29 days (IQR 15-46 days) versus 23 days (IQR 11-39 days), p=.64; (3) 14 days (IQR 7-21 days) versus 14 days (IQR 12-21 days), p=.32. Multivariable logistic regression showed marginal associations between gestational age at suspicion of pregnancy and no prior pregnancy (aOR=3.8, 95% CI 1.0-14.6) and living in informal housing (aOR=3.1, 95% CI 1.0-9.1). Gestational age on the day of the abortion procedure was significantly associated with living in informal housing (aOR=3.1, 95% CI 1.4-6.6). CONCLUSION The only differences in delay in obtaining second trimester abortion between South African women having an earlier and later second trimester procedure is due to longer time to suspect pregnancy. IMPLICATIONS Interventions to improve early pregnancy recognition should be explored and referral processes should be streamlined to avoid unnecessary delays accessing abortion care and possibly reduce the proportion of abortions performed later in the second trimester in South Africa.
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Affiliation(s)
- Deborah Constant
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Judy Kluge
- Department of Obstetrics & Gynaecology, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa.
| | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Daniel Grossman
- 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, Oakland, California, USA.
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8
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The costs and cost effectiveness of providing second-trimester medical and surgical safe abortion services in Western Cape Province, South Africa. PLoS One 2018; 13:e0197485. [PMID: 29953434 PMCID: PMC6023192 DOI: 10.1371/journal.pone.0197485] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 05/03/2018] [Indexed: 11/19/2022] Open
Abstract
Background In South Africa, access to second-trimester abortion services, which are generally performed using medical induction with misoprostol alone, is challenging for many women. We aimed to estimate the costs and cost effectiveness of providing three safe second-trimester abortion services (dilation and evacuation (D&E)), medical induction with mifepristone and misoprostol (MI-combined), or medical induction with misoprostol alone (MI-misoprostol)) in Western Cape Province, South Africa to aid policymakers with planning for service provision in South Africa and similar settings. Methods We derived clinical outcomes data for this economic evaluation from two previously conducted clinical studies. In 2013–2014, we collected cost data from three public hospitals where the studies took place. We collected cost data from the health service perspective through micro-costing activities, including discussions with site staff. We used decision tree analysis to estimate average costs per patient interaction (e.g. first visit, procedure visit, etc.), the total average cost per procedure, and cost-effectiveness in terms of the cost per complete abortion. We discounted equipment costs at 3%, and present the results in 2015 US dollars. Results D&E services were the least costly and the most cost-effective at $91.17 per complete abortion. MI-combined was also less costly and more cost-effective (at $298.03 per complete abortion) than MI-misoprostol (at $375.31 per complete abortion), in part due to a shortened inpatient stay. However, an overlap in the plausible cost ranges for the two medical procedures suggests that the two may have equivalent costs in some circumstances. Conclusion D&E was most cost-effective in this analysis. However, due to resistance from health care providers and other barriers, these services are not widely available and scale-up is challenging. Given South Africa’s reliance on medical induction, switching to the combined regimen could result in greater access to second-trimester services due to shorter inpatient stays without increasing costs.
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9
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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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10
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Cruz RP, Scheffler MH, da Silva DM, Guedes Neto EDP, Savaris RF. Moistening the new vaginal misoprostol tablets: does it increase the efficacy of cervical priming before manual vacuum aspiration in first-trimester miscarriage? A randomised clinical trial. EUR J CONTRACEP REPR 2017; 22:407-411. [PMID: 29250974 DOI: 10.1080/13625187.2017.1406077] [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] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The primary objective of our study was to ascertain whether moistening the Brazilian formulation of vaginal misoprostol tablets increases cervical dilation before manual vacuum aspiration (MVA), compared with use of dry misoprostol, in first-trimester miscarriage. The secondary objective was to ascertain whether there was any correlation between vaginal pH and the degree of cervical dilation using a moistened or dry misoprostol tablet. METHODS In a single-centre, double-blind, randomised trial, 46 patients with first-trimester miscarriage were randomly allocated to treatment with dry or moistened (with 200 µl distilled water) 2 × 200 μg misoprostol tablets. RESULTS The median (range) cervical dilation in the wet and dry groups was 8 mm (6-12 mm) and 7 mm (5-10 mm), respectively (p = .06). The median time between misoprostol insertion and carrying out the procedure did not differ between the dry (406 min, range 180-550 min) and wet (448 min, range 180-526 min) groups (p = .1). No correlation was found between vaginal pH and cervical dilation using continuous data (p = .57; r= 0.08; 95% confidence interval -0.02, 0.3) or dichotomous data (pH ≤5/>5; cervical dilation ≥8 mm or <8 mm; p = .8). CONCLUSION No difference was observed in cervical dilation between moistened and non-moistened misoprostol use prior to MVA.
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Affiliation(s)
- Ricardo Pedrini Cruz
- a Programa de Pós-Graduação em Ciências da Saúde - Ginecologia e Obstetrícia , Universidade Federal do Rio Grande do Sul , Porto Alegre , Brazil
| | - Mariana Hollmann Scheffler
- b Department of Gynaecology and Obstetrics , Universidade Federal do Rio Grande do Sul , Porto Alegre , Brazil
| | - Daniel Mendes da Silva
- a Programa de Pós-Graduação em Ciências da Saúde - Ginecologia e Obstetrícia , Universidade Federal do Rio Grande do Sul , Porto Alegre , Brazil
| | | | - Ricardo Francalacci Savaris
- b Department of Gynaecology and Obstetrics , Universidade Federal do Rio Grande do Sul , Porto Alegre , Brazil
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11
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Shaw KA, Lerma K, Shaw JG, Scrivner KJ, Hugin M, Hopkins FW, Blumenthal PD. Preoperative effects of mifepristone for dilation and evacuation after 19 weeks of gestation: a randomised controlled trial. BJOG 2017; 124:1973-1981. [DOI: 10.1111/1471-0528.14900] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2017] [Indexed: 11/30/2022]
Affiliation(s)
- KA Shaw
- Division of Family Planning Services and Research; Department of Obstetrics & Gynecology; Stanford University School of Medicine; Stanford CA USA
| | - K Lerma
- Division of Family Planning Services and Research; Department of Obstetrics & Gynecology; Stanford University School of Medicine; Stanford CA USA
| | - JG Shaw
- Division of Primary Care and Population Health; Department of Medicine; Stanford University School of Medicine; Stanford CA USA
| | - KJ Scrivner
- Division of Family Planning Services and Research; Department of Obstetrics & Gynecology; Stanford University School of Medicine; Stanford CA USA
| | - M Hugin
- Department of Obstetrics & Gynecology; Santa Clara Valley Medical Center; San Jose CA USA
| | - FW Hopkins
- Division of Family Planning Services and Research; Department of Obstetrics & Gynecology; Stanford University School of Medicine; Stanford CA USA
- Department of Obstetrics & Gynecology; Santa Clara Valley Medical Center; San Jose CA USA
| | - PD Blumenthal
- Division of Family Planning Services and Research; Department of Obstetrics & Gynecology; Stanford University School of Medicine; Stanford CA USA
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Lince-Deroche N, Harries J, Constant D, Morroni C, Pleaner M, Fetters T, Grossman D, Blanchard K, Sinanovic E. Doing more for less: identifying opportunities to expand public sector access to safe abortion in South Africa through budget impact analysis. Contraception 2017; 97:167-176. [PMID: 28780240 DOI: 10.1016/j.contraception.2017.07.165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 06/17/2017] [Accepted: 07/25/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE(S) To estimate the costs of public-sector abortion provision in South Africa and to explore the potential for expanding access at reduced cost by changing the mix of technologies used. STUDY DESIGN We conducted a budget impact analysis using public sector abortion statistics and published cost data. We estimated the total costs to the public health service over 10 years, starting in South Africa's financial year 2016/17, given four scenarios: (1) holding service provision constant, (2) expanding public sector provision, (3) changing the abortion technologies used (i.e. the method mix), and (4) expansion plus changing the method mix. RESULTS The public sector performed an estimated 20% of the expected total number of abortions in 2016/17; 26% and 54% of all abortions were performed illegally or in the private sector respectively. Costs were lowest in scenarios where method mix shifting occurred. Holding the proportion of abortions performed in the public-sector constant, shifting to more cost-effective service provision (more first-trimester services with more medication abortion and using the combined regimen for medical induction in the second trimester) could result in savings of $28.1 million in the public health service over the 10-year period. Expanding public sector provision through elimination of unsafe abortions would require an additional $192.5 million. CONCLUSIONS South Africa can provide more safe abortions for less money in the public sector through shifting the methods provided. More research is needed to understand whether the cost of expanding access could be offset by savings from averting costs of managing unsafe abortions. IMPLICATIONS South Africa can provide more safe abortions for less money in the public sector through shifting to more first-trimester methods, including more medication abortion, and shifting to a combined mifepristone plus misoprostol regimen for second trimester medical induction. Expanding access in addition to method mix changes would require additional funds.
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Affiliation(s)
| | - Jane Harries
- Women's Health Research Unit, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Deborah Constant
- Women's Health Research Unit, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Chelsea Morroni
- Women's Health Research Unit, School of Public Health, University of Cape Town, Cape Town, South Africa; EGA Institute for Women's Health and Institute for Global Health, University College London, London, UK
| | - Melanie Pleaner
- Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Daniel Grossman
- Ibis Reproductive Health, Oakland, CA, USA; 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, Oakland, CA, USA
| | | | - Edina Sinanovic
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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13
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Fink G, Gerber S, Dean G. Misoprostol in Abortion Care: Review and Update. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0202-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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14
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Ndounga Diakou LA, Ntoumi F, Ravaud P, Boutron I. Published randomized trials performed in Sub-Saharan Africa focus on high-burden diseases but are frequently funded and led by high-income countries. J Clin Epidemiol 2017; 82:29-36.e6. [DOI: 10.1016/j.jclinepi.2016.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 10/10/2016] [Accepted: 10/26/2016] [Indexed: 01/05/2023]
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15
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Khooshideh M, Yarmohammadi N, Shahriari A, Sheikh M. Sublingual misoprostol plus laminaria for cervical preparation before surgical management of late first trimester missed abortions, a randomized controlled trial. J Matern Fetal Neonatal Med 2017; 30:317-322. [PMID: 27020489 DOI: 10.3109/14767058.2016.1171838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 03/24/2016] [Accepted: 03/24/2016] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Comparing the efficacy of low-dose sublingual misoprostol plus laminaria to medium-dose sublingual misoprostol alone for cervical dilation before surgical management of late first trimester missed abortions. METHODS Randomized, controlled trial evaluated 70 women with missed abortion, admitted for surgical termination of pregnancy. The patients were randomly assigned to receive 200 μg sublingual misoprostol with cervical laminaria (intervention group) or 400 μg sublingual misoprostol without laminaria (control group), four hours before surgical process. The study is registered at www.irct.ir (IRCT2014070711020N4). RESULTS More patients in the intervention group achieved the desired cervical dilation (≥Hegar7) before surgical process than the control group (91.4% versus 17.1%, p < 0.001). Patients in the intervention group experienced less pain during the waiting period (mean Visual Analog Scale scores: 30.8 ± 3.7 versus 43.7 ± 5.9, p < 0.001), and had higher satisfaction level (highly satisfied: 97.1% versus 77.1%, p = 0.02). Four patients in the intervention group and none in the control group had spontaneous expulsion of pregnancy products (p = 0.11). CONCLUSIONS Compared to medium-dose sublingual misoprostol alone, using a combination of cervical laminaria plus low-dose sublingual misoprostol before surgical process is associated with significantly more effective and rapid cervical dilation, lower requirement for mechanical dilation, lower abdominal pain and discomfort during the waiting period and higher patients' satisfaction.
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Affiliation(s)
- Maryam Khooshideh
- a Department of Obstetrics and Gynecology , Arash Women's Hospital, Tehran University of Medical Sciences , Tehran , Iran
| | - Nasim Yarmohammadi
- a Department of Obstetrics and Gynecology , Arash Women's Hospital, Tehran University of Medical Sciences , Tehran , Iran
| | - Ali Shahriari
- b Department of Anesthesiology , Roozbeh Hospital, Tehran University of Medical Sciences , Tehran , Iran , and
| | - Mahdi Sheikh
- c Maternal, Fetal and Neonatal Research Center, Vali-Asr Hospital, Tehran University of Medical Sciences , Tehran , Iran
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Abstract
PURPOSE OF REVIEW To review the recent literature on surgical second-trimester abortion, with specific attention to cervical preparation techniques. RECENT FINDINGS Confirming previous studies, a recent retrospective observational cohort study, including 54 911 abortions, estimated the total abortion-related complication rate to be 0.41% for second-trimester or later procedures. Cervical preparation is known to reduce risks associated with second-trimester dilation and evacuation (D&E). When considering adjuncts to osmotic dilators for cervical preparation prior to D&E after 16 weeks, both misoprostol and mifepristone are effective alone and in combination or as adjuncts to osmotic dilators. Misoprostol consistently has been shown to cause more pain and cramping than placebo, but is an effective adjunct to osmotic dilators after 16 weeks. Although mifepristone has fewer side-effects, at its current price, it may not be as cost-effective as misoprostol. SUMMARY Second-trimester abortion is safe. The use of mifepristone and misoprostol for second-trimester abortion has improved safety and efficacy of medical and surgical methods when used alone or in combination and as adjuncts to osmotic dilators. An important aspect of D&E, cervical preparation, is not a one-size-fits-all practice; the approach and methods are contingent on patient, provider and setting and should consider all the evidence-based options.
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Sagiv R, Mizrachi Y, Glickman H, Kerner R, Keidar R, Bar J, Golan A. Laminaria vs. vaginal misoprostol for cervical preparation before second-trimester surgical abortion: a randomized clinical trial. Contraception 2015; 91:406-11. [PMID: 25646929 DOI: 10.1016/j.contraception.2015.01.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 01/27/2015] [Accepted: 01/27/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare the efficacy and tolerability of vaginal misoprostol and laminaria for cervical preparation before second-trimester surgical abortion. STUDY DESIGN We performed a prospective, randomized trial comparing midnight administration of misoprostol 600 mcg vaginally to midnight placement of laminaria, before surgical abortions among women at 13-20 weeks of gestation. The primary outcome was preoperative cervical dilation. Secondary outcomes were the need for further dilation, procedure duration and difficulty, immediate complications and side effects. RESULTS Eighty-four women were randomized, with a median gestational age of 16.5 weeks. The mean time interval between misoprostol and laminaria placement and dilatation and evacuation initiation was 11.0±2.9 and 11.2±2.0h, respectively (p=.17). Cervical dilation was not greater in the laminaria group as compared to the misoprostol group (12.8 vs. 12.4mm, respectively; p=.32). No difference was demonstrated regarding the need for additional dilation or the difficulty of the procedure. Procedures performed after laminaria insertion were 1 min longer (median 11 vs. 10 min, p=.04). Participants found laminaria placement more uncomfortable than vaginal misoprostol placement. Other than pain, additional side effects occurred only in the misoprostol group, primarily nausea and vomiting. One participant in the misoprostol group experienced fetal expulsion during the night before the intended procedure. CONCLUSION Either vaginal misoprostol or laminaria provides adequate dilation for second-trimester surgical abortion. Laminaria causes more pain at insertion and misoprostol causes more side effects. IMPLICATIONS STATEMENT We found that cervical preparation in an inpatient setting for approximately 11h with misoprostol 600 mcg vaginally is comparable to 11h of laminaria. However, given the potential for spontaneous expulsion and more side effects with misoprostol, laminaria is likely a better general option in such a setting.
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Affiliation(s)
- Ron Sagiv
- Department of Obstetrics and Gynecology, E. Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Yossi Mizrachi
- Department of Obstetrics and Gynecology, E. Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hagit Glickman
- Department of Obstetrics and Gynecology, E. Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ram Kerner
- Department of Obstetrics and Gynecology, E. Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ran Keidar
- Department of Obstetrics and Gynecology, E. Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jacob Bar
- Department of Obstetrics and Gynecology, E. Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Abraham Golan
- Department of Obstetrics and Gynecology, E. Wolfson Medical Center, Holon, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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