Cervical dilation before first-trimester surgical abortion (<14 weeks' gestation)

Abortion Return Rates and Wait Times Before and After Texas' Executive Order Banning Abortion During COVID-19

Objectives. To assess the associations between the executive order that Texas governor Greg Abbott issued on March 22, 2020, postponing procedures deemed not immediately medically necessary, and patients' access to abortion care in Texas. Methods. We used 17 515 individual-level patient records from 13 Texas abortion facilities for matched periods in 2019 and 2020 to examine differences in return rates for abortion after completion of a state-mandated ultrasound and median wait times between ultrasound and abortion visits for those who returned. Results. Patients were less likely to return for an abortion if they had an ultrasound while the executive order was under effect (82.8%) than in the same period in 2019 (90.4%; adjusted odds ratio = 2.06; 95% confidence interval = 1.12, 3.81). Compared with patients at or before 10.0 weeks' gestation at ultrasound, patients at more than 10 weeks' gestation had higher odds of not returning for an abortion or, if they returned, experienced greater wait times between ultrasound and abortion visits. Conclusions. Texas' executive order prohibiting abortion during the COVID-19 pandemic disrupted patients' access to care and disproportionately affected patients who were past 10 weeks' gestation. (Am J Public Health. 2024;114(10):1013-1023. https://doi.org/10.2105/AJPH.2024.307747).

First-trimester Procedural Abortion

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.

First and Second-Trimester Surgical Abortion Providers and Services in 2019: Results From the Canadian Abortion Provider Survey

OBJECTIVE

Our objective was to explore the workforce and clinical care of first and second-trimester surgical abortion (FTSA, STSA) providers following the publication of the updated Society of Obstetricians and Gynaecologists of Canada (SOGC) surgical abortion guidelines.

METHODS

We conducted a national, cross-sectional, online, self-administered survey of physicians who provided abortion care in 2019. This anonymized survey collected participant demographics, types of abortion services, and characteristics of FTSA and STSA clinical care. Through healthcare organizations using a modified Dillman technique, we recruited from July to December 2020. Descriptive statistics were generated by R Statistical Software.

RESULTS

We present the data of 222 surgical abortion provider respondents, of whom 219 provided FTSA, 109 STSA, and 106 both. Respondents practiced in every Canadian province and territory. Most were obstetrician-gynaecologists (56.8%) and family physicians (36.0%). The majority of FTSA and STSA respondents were located in urban settings, 64.8% and 79.8%, respectively, and more than 80% practiced in hospitals. More than 1 in 4 respondents reported <5 years' experience with surgical abortion care and 93.2% followed SOGC guidelines. Noted guideline deviations included that prophylactic antibiotic use was not universal, and more than half of respondents used sharp curettage in addition to suction. Fewer than 5% of STSA respondents used mifepristone for cervical preparation.

CONCLUSION

The surgical abortion workforce is multidisciplinary and rejuvenating. Education, training, and practice support, including SOGC guideline implementation, are required to optimize care and to ensure equitable FTSA and STSA access in both rural and urban regions. GESTATIONAL AGE NOTATION: weeks, weeks' gestation, gestational age (GA), e.g., 116 weeks.

Vaginal Bleeding Before 20 Weeks Gestation

Conditions that often present with vaginal bleeding before 20 weeks are common and can cause morbidity and mortality. Clinically stable patients can choose their management options. Clinically unstable patients require urgent procedural management: uterine aspiration, dilation and evacuation, or surgical removal of an ectopic pregnancy. Septic abortion requires prompt procedural management, intravenous antibiotics, and intravenous fluids. Available data on prognosis with expectant management of pre-viable rupture of membranes in the United States are poor for mothers and fetuses.

Association of Texas' 2021 Ban on Abortion in Early Pregnancy With the Number of Facility-Based Abortions in Texas and Surrounding States

Importance

Texas' 2021 ban on abortion in early pregnancy may demonstrate how patterns of abortion might change following the US Supreme Court's June 2022 decision overturning Roe v Wade.

Objective

To assess changes in the number of abortions and changes in the percentage of out-of-state abortions among Texas residents performed at 12 or more weeks of gestation in the first 6 months following implementation of Texas Senate Bill 8 (SB 8), which prohibited abortions after detection of embryonic cardiac activity.

Design, Setting, and Participants

Retrospective study of a sample of 50 Texas and out-of-state abortion facilities using an interrupted time series analysis to assess changes in the number of abortions, and Poisson regression to assess changes in abortions at 12 or more weeks of gestation. Data included 68 820 Texas facility-based abortions and 11 287 out-of-state abortions among Texas residents during the study period from September 1, 2020, to February 28, 2022.

Exposures

Abortion care obtained after (September 2021-February 2022) vs before (September 2020-August 2021) implementation of SB 8.

Main Outcomes and Measures

Primary outcomes were changes in the number of facility-based abortions for Texas residents, in Texas and out of state, in the month after implementation of SB 8 compared with the month before. The secondary outcome was the change in the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation during the 6-month period after the law's implementation.

Results

Between September 2020 and August 2021, there were 55 018 abortions in Texas and 2547 out-of-state abortions among Texas residents. During the 6 months after SB 8, there were 13 802 abortions in Texas and 8740 out-of-state abortions among Texas residents. Compared with the month before implementation of SB 8, the number of Texas facility-based abortions significantly decreased from 5451 to 2169 (difference, -3282 [95% CI, -3171 to -3396]; incidence rate ratio [IRR], 0.43 [95% CI, 0.36-0.51]) in the month after SB 8 was implemented. The number of out-of-state abortions among Texas residents significantly increased from 222 to 1332 (difference, 1110 [95% CI, 1047-1177]; IRR, 5.38 [95% CI, 4.19-6.91]). Overall, the total documented number of Texas facility-based and out-of-state abortions among Texas residents significantly decreased from 5673 to 3501 (absolute change, -2172 [95% CI, -2083 to -2265]; IRR, 0.67 [95% CI, 0.56-0.79]) in the first month after SB 8 was implemented compared with the previous month. Out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation increased from 17.1% (221/1291) to 31.0% (399/1289) (difference, 178 [95% CI, 153-206]) during the period between September 2021 and February 2022 (P < .001 for trend).

Conclusions and Relevance

Among a sample of abortion facilities, the 2021 Texas law banning abortion in early pregnancy (SB 8) was significantly associated with a decrease in the documented total of facility-based abortions in Texas and obtained by Texas residents in surrounding states in the first month after implementation compared with the previous month. Over the 6 months following SB 8 implementation, the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation significantly increased.

Abortion as Essential Health Care and the Critical Role Your Practice Can Play in Protecting Abortion Access

Few obstetrician-gynecologists (ob-gyns) provide abortion care, resulting in abortion being separated from other reproductive health care. This segregation of services disrupts the ob-gyn patient-clinician relationship, generates needless costs, delays access to abortion care, and contributes to stigma. General ob-gyns have both the skills and the knowledge to incorporate abortion into their clinical practices. In this way, they can actively contribute to the protection of abortion access now with the loss of federal protection for abortion under Roe v Wade . For those who live where abortion remains legal, now is the time to start providing abortions and enhancing your abortion-referral process. For all, regardless of state legislation, ob-gyns must be leaders in advocacy by facilitating abortion care-across state lines, using telehealth, or with self-managed abortion-and avoiding any contribution to the criminalization of those who seek or obtain essential abortion care. Our patients deserve a specialty-wide concerted effort to deliver comprehensive reproductive health care to the fullest extent.

[Interruption of pregnancy between 12 and 16 weeks of gestation: Complications depending on term and method]

OBJECTIVE

Analyze the complication rate of pregnancy termination between 12 and 16 weeks of gestation, depending on the method and the exact term.

MATERIAL AND METHODS

Retrospective study focuses on patients who were going through a pregnancy termination between January 2015 and December 2020 at the Necker Universitary hospital in Paris. Two methods were applied: surgical abortion or medical evacuation. We compared 4 groups of patients depending on methods and term (12-14 or 14-16 weeks of gestation). The main complications such as hemorrhage, infection, need for surgery were collected.

RESULTS

414 patients were included. Blood loss and hemorrhage rate>500cc were higher for surgical abortion (3.5 vs 55% P<0.001), but the medical evacuation lead to an important rate of secondary aspiration for trophoblastic retention (14.7% vs 1.5% P<0.001). We didn't observe any difference regarding the complication rate for medical evacuation depending on the term. However, in case of surgical abortion the increase of term from 12-14 to 14-16 weeks of gestation leads to a tiny increment of the transfusion rate (0.6% vs 4.4% P=0.04), even if the hemorrhage rate >500cc didn't significantly differ (50,3 vs 57,9% P=0,2).

CONCLUSION

Surgical abortion between 12 and 16 weeks of gestation exposed the patients to an increased hemorrhagic risk, while the medical evacuation required more secondary aspiration for trophoblastic retention. The term of the abortion didn't affect the complication rate, beside a tiny increase in transfusion rate for surgical abortion.

Abortion at 12 or more weeks' gestation and travel for later abortion care among Mississippi residents

OBJECTIVE

To assess the association between indicators of economic disadvantage and geographic accessibility of reproductive health services and abortions ≥ 12 weeks' gestation in Mississippi.

STUDY DESIGN

This cross-sectional study used data on Mississippi residents who obtained abortion care from 12 of 14 facilities in Mississippi, Alabama, Louisiana, and Tennessee in 2018. We estimated logistic regression models to assess the association between levels of county deprivation, the number of obstetrician and/or gynecologists per 10,000 women, and one way distance to the nearest facility with having an abortion ≥ 12 weeks' gestation. We compared the median one-way distance to the facility where patients < 12 weeks', 12-15 weeks', and ≥ 16 weeks' gestation received care, using Kruskal-Wallis tests.

RESULTS

Of the 4,455 Mississippi residents who obtained abortions, 73% were Black, 59% lived ≥ 50 miles from a facility, and 60% obtained care in Mississippi. Overall, 764 (17.2%) abortions were performed ≥ 12 weeks' gestation. In adjusted models, those in counties with moderate (OR, 1.47; 95% CI: 1.15-1.90) and high (OR: 1.36, 95% CI: 1.01-1.83) (vs low) levels of economic deprivation and counties with 0.1-1.4 (vs ≥ 2.5) obstetrician/gynecologists per 10,000 women (OR: 1.55; 95% CI: 1.06-2.27) had higher odds of obtaining an abortion ≥12 weeks' gestation. Mississippi residents who obtained abortions ≥ 16 weeks' gestation traveled a median 143 miles one way to the facility where they received care, compared to 69 miles and 60 miles traveled by those < 12 weeks' and 12-15 weeks' gestation, respectively (p < .001).

CONCLUSIONS

Many Mississippi residents obtained abortion care ≥ 12 weeks' gestation, which is related to greater economic constraints and limited geographic access to reproductive health services.

IMPLICATIONS

People's need for abortions ≥ 12 weeks' gestation may be higher in communities with limited access to reproductive health services and among those living in areas with greater economic disadvantage. State laws that narrow gestational limits would increase long-distance travel for later abortion care, and disproportionately affect those with fewer resources.

Lower and extended dosage of misoprostol for cervical ripening in 1st trimester miscarriage (MISO200): A randomized clinical trial

OBJECTIVE

To compare the efficacy of priming the uterine cervix before Manual Vaccum Aspiration (MVA) using 200 µg or 400 µg of vaginal misoprostol, inserted a mean time of 6 h before MVA in first trimester miscarriage.

STUDY DESIGN

Randomized, triple-blind, non-inferiority clinical trial. Patients between 18 and 50 years old, with a diagnosis of miscarriage, were eligible for the study. Patients were allocated to receive either 200 μg or 400 µg of misoprostol before the MVA. The primary outcome was the need to dilate the uterine cervix with mechanical dilators (Hegar dilators). As a secondary outcome, cervical dilatation ≥8 mm before the procedure was considered successful. A difference of <25% was considered as non-inferior.

RESULTS

Between December 21, 2016 and October 6, 2019, 269 women were screened. After screening, 105 and 106 women received 200 µg and 400 µg of misoprostol, respectively. Mechanical cervical dilatation was not necessary in 84.8% (95%CI 77% to 90%) and 96.2% (95%CI 91% to 99%), in the 200 µg and 400 µg groups, respectively [difference = 11.5% (95%CI 3.7% to 19.2%). Cervical dilatation of ≥8 mm was 52.4% (95%CI 42.9% to 61.7%) in the 200 µg misoprostol group, while in the 400 µg group was 71.7% (95%CI 62.5% to 79.4%) [difference = 19.3% (95%CI 6.5 to 32.2).

CONCLUSION

After a mean time of 6 h, 200 µg of vaginal misoprostol is not inferior to 400 µg of misoprostol for cervical priming before MVA, in first trimester miscarriage. This non-inferiority was not observed when the ≥8 mm criterion was considered.

Pain Associated With Cervical Priming for First-Trimester Surgical Abortion: A Randomized Controlled Trial

OBJECTIVE

To compare the effect of cervical priming with mifepristone with that of misoprostol on pain perception during surgical induced abortion under paracervical block.

METHODS

We conducted a randomized, single-blind, two-center study of women undergoing surgical induced abortion at less than 14 weeks of gestation under paracervical block. Participants were randomized to receive cervical priming with 200 mg of oral mifepristone 36 hours or 400 micrograms buccal misoprostol 3 hours before surgery. The primary outcome was pain during mechanical cervical dilation evaluated by a 100-mm visual analog scale (VAS). Secondary outcomes were pain during aspiration, preoperative and postoperative pain, participant satisfaction, duration of the procedure, occurrence of complications, and ease of performing the procedure (assessed by a 100-mm VAS). We estimated that 110 women would have to be included to have 90% power to detect a 13mm-difference of VAS for pain.

RESULTS

Between June 2017 and May 2019, 314 women were eligible and 110 were randomized (55 in each group). Patient characteristics were similar in the two groups. The mean VAS score during mechanical cervical dilation was lower in the mifepristone group (35.6±21 vs 43.5±21, P=.04) as was the mean VAS during aspiration (34±24 vs 47.8±23, P=.003). The preoperative and postoperative mean VAS, satisfaction and duration of procedures were similar between groups. The procedure was significantly easier to perform in the mifepristone group (88±16 vs 80±23, P=.004).

CONCLUSION

Cervical priming with mifepristone for surgical induced abortion under paracervical block up to 14 weeks of gestation is more effective than misoprostol in reducing pain perception.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03043014.

A comparative clinical trial of vaginal misoprostol versus intracervical normal saline infiltration as a cervical ripening agent at time of hysteroscopy

Cervical status has a great impact on the duration and success of its dilatation especially during hysteroscopy, so cervical ripening employed before the procedure can increase the success rate and minimize the complications.

AIM

To compare the efficacy of vaginal misoprostol and intracervical normal saline infiltration as cervical ripening agents.

METHODS

A randomized comparative clinical trial had been conducted in AL Yarmouk Teaching Hospital involving two methods for cervical ripening before the hysteroscopic procedure. One Hundred women were enrolled in the study, fifty of them were those who used preoperative vaginal misoprostol and the other fifty patients were those who had been submitted to intracervical normal saline infiltration during surgery. Basal cervical dilatation, time to achieve 8 mm cervical dilatation, difficulties, and complications encountered during the procedure were evaluated and compared for both groups.

RESULTS

The participants had been admitted for hysteroscopy for the following indications: Abnormal uterine bleeding, missed loop, infertility, polypectomy, endometrial resection, and myomectomy. Regarding operative findings, the basal cervical dilatation was not significantly different between them, the time required to achieve the required dilatation was significantly shorter for the normal saline infiltration group, 66.95 sec. ± 10.85 than for the misoprostol group which was 87.9 sec. ± 13.11. There was more difficulty in dilatation with more complications in the misoprostol group than in the normal saline infiltration group.

CONCLUSIONS

Normal saline infiltration is a simple, readily available at the time of surgery and with fewer complications and shorter time of dilatation in comparison to vaginal misoprostol for a comparable efficacy.

Change in Second-Trimester Abortion After Implementation of a Restrictive State Law

OBJECTIVE

To assess whether indicators of limited access to services explained changes in rates of second-trimester abortion after implementation of a restrictive abortion law in Texas.

METHODS

We used cross-sectional vital statistics data on abortions performed in Texas before (November 1, 2011-October 31, 2012) and after (November 1, 2013-October 31, 2014) implementation of Texas' abortion law. We conducted monthly mystery client calls for information about abortion facility closures and appointment wait times to calculate distance from women's county of residence to the nearest open Texas facility, the number of open abortion facilities in women's region of residence (facility network size), and days until the next consultation visit. We estimated mixed-effects logistic regression models to assess the association between obtaining abortion care after the law's implementation and having a second-trimester abortion (12 weeks of gestation or more), after adjustment for distance, network size, and wait times.

RESULTS

Overall, 64,902 Texas-resident abortions occurred in the period before the law was introduced and 53,174 occurred after its implementation. After implementation, 14.5% of abortions were performed at 12 weeks of gestation or more, compared with 10.5% before the law (P<.001; unadjusted odds ratio [OR] 1.45; 95% CI 1.40-1.50). Adjusting for distance to the nearest facility and facility network size reduced the odds of having a second-trimester abortion after implementation (OR 1.17; 95% CI 1.10-1.25). Women living 50-99 miles from the nearest facility (vs less than 10 miles) had higher odds of second-trimester abortion (OR 1.24; 95% CI 1.11-1.39), as did women in regions with less than one facility per 250,000 reproductive-aged women compared with women in areas that had 1.5 or more facilities (OR 1.57; 95% CI 1.41-1.75). After implementation, women waited 1 to 14 days for a consultation visit; longer waits were associated with higher odds of second-trimester abortion.

CONCLUSION

Increases in second-trimester abortion after the law's implementation were due to women having more limited access to abortion services.

No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods

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.

Adjunctive Agents for Cervical Preparation in Second Trimester Surgical Abortion

Late second trimester dilation and evacuation is a challenging subset of surgical abortion. Among the reasons for this is the degree of cervical dilation required to safely extricate fetal parts. Cervical dilation is traditionally achieved by placing multiple sets of osmotic dilators over two or more days prior to the evacuation procedure; however, there is interest in shortening cervical preparation time. The use of adjuvant mifepristone and misoprostol in conjunction with osmotic dilators has been studied for this purpose, and their use demonstrates that adequate cervical dilation can be achieved in less time than with dilators alone. We present a review of the current evidence surrounding adjunctive agents for cervical preparation, and contend that for women presenting for surgical abortion care above 19 weeks gestation, the use of adjunctive mifepristone and/or misoprostol should be strongly considered along with osmotic dilator insertion when cervical preparation in less than 24 h is needed.

Massachusetts' Parental Consent Law and Procedural Timing Among Adolescents Undergoing Abortion

OBJECTIVE

To describe individual-level delay in obtaining abortion associated with use of the Massachusetts judicial bypass system, which legal minors (aged 17 years or younger) use to obtain abortion without consent of a parent or legal guardian in the setting of Massachusetts' parental consent law for abortion.

METHODS

We conducted a retrospective cohort study of 2,026 abortions among minors at a large, statewide network of abortion clinics between 2010 and 2016. Delay was defined as the number of calendar days between the minor's first call to the clinic to schedule an abortion, and the day the abortion was received.

RESULTS

In the study population, 1,559 (77%) abortions were obtained with parental consent and 467 (23%) using judicial bypass. Abortions after judicial bypass were more common among minors identifying as Hispanic, non-Hispanic black, or other race, those of low socioeconomic status (as indicated by having Medicaid insurance) and those with a prior birth or prior abortion (all P<.05). Minors with parental consent received their abortion a mean of 8.6 days after initial contact, compared with 14.8 days for minors with judicial bypass, for an unadjusted difference of 6.1 days. In multivariable linear regression modeling adjusting for demographic differences between groups, this difference persisted: minors who obtained abortions after judicial bypass had a significantly greater delay compared with those with parental consent (adjusted mean difference = 5.2 days; 95% CI 4.3 to 6.2). Using multivariable logistic regression modeling, minors with judicial bypass also had higher odds of becoming ineligible for medication abortion between the day of first call and the day of procedure (adjusted odds ratio 1.57; 95% CI 1.09 to 2.26).

CONCLUSION

Massachusetts' parental consent law for abortion is associated with delay among minors and thereby may constrain the clinical options available to them.

Single versus multiple cervical dilation by osmotic dilator before induction of labor for second-trimester abortion

AIM

In this study, we aimed to investigate whether there was a significant prognostic difference between single and multiple cervical dilations when inducing second-trimester abortion.

METHODS

We conducted a retrospective review of 238 pregnant women who underwent termination of pregnancy at 12-21 weeks of gestation at Osaka University Hospital in Osaka, Japan, between January 2010 and May 2018. Termination of pregnancy was performed by vaginal administration of 1 mg gemeprost every 3 h for up to five doses per day after uterine cervical dilation using lamicel.

RESULTS

The women were categorized into two groups: 191 women had a delivery time of <24 h, whereas 47 had delivery times >24 h. Contrasting the groups, there were significant differences with regard to numbers of primiparas (88 [46.1%] and 32 [68.1%], respectively) and lamicel exchanges ± SD (1.9 ± 0.67 for <24 h and 2.4 ± 0.87 for >24 h, respectively). Additionally, we compared the prognosis of primiparas that received just a single lamicel with that of primiparas that had ≥2 exchanged, but no significant differences were noted in the number of patients with a delivery time of >24 h and the number of used gemeprost.

CONCLUSION

Primipara is a risk factor for delayed delivery time of induced abortion. However, increasing the number of exchanged lamicel did not significantly reduce the delivery time; therefore, it should be performed as minimally as possible.

Clinical pitfalls in misoprostol-based medical management of first-trimester induced and presumed spontaneous abortion

When administered inappropriately, first-trimester misoprostol management of induced or spontaneous abortion can result in loss or damage of a continuing pregnancy. Despite these serious consequences, such misoprostol exposures continue to occur. Unfortunately, contributing factors and preventive measures receive little attention. We describe the cases of 4 women in whom misoprostol was inappropriately administered during management of induced and presumed spontaneous abortion. In each case, careful adherence to published clinical guidance could have avoided the exposures.

Standardizing the classification of abortion incidents: the Procedural Abortion Incident Reporting and Surveillance (PAIRS) Framework

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.

Different routes of misoprostol for cervical priming in first trimester surgical abortions: a randomized blind trial

PURPOSE

To compare effectiveness and patient satisfaction of different routes of misoprostol for short-term (same day) cervical priming in first trimester surgical abortions.

METHODS

In a blind randomized trial, patients undergoing surgical abortion at a gestational age of 6 + 0-14 + 6 were administered oral, vaginal, or sub-lingual 400 mcg misoprostol, 1.5 to 4 h prior to procedure. Surgeons blinded to patient allocation evaluated cervical priming. The primary outcome was initial cervical dilatation. Secondary outcomes were cervical consistency, ease of dilation, patient discomfort, and side effects.

RESULTS

From July 2015 through May 2016, 120 patients were randomized as follows: 40 to oral, 40 to vaginal, and 40 to sublingual misoprostol administration. No differences were noted in patient age, gestational age, curettage indication (termination/delayed miscarriage), past vaginal delivery, and administration to procedure interval. Initial cervical dilatation was similar between the groups, as were cervical consistency and ease of dilation. Patients noted the greatest discomfort and side effects with sublingual administration. The followings were found to be independently associated with cervical dilatation in a linear regression analysis: sublingual administration, gestational age, missed abortion, and previous vaginal delivery. Side effects and administration to procedure interval were found non-significant.

CONCLUSION

The same day cervical priming for first trimester surgical abortion is similarly achieved with all routes of misoprostol administration. In cases of termination of pregnancy with no prior vaginal delivery, sublingual administration may be considered, but entails a higher rate of side effects and patient discomfort.