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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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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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3
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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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Fang P, Qian J, Ding J, Pan X, Su H, Liu X. Comparison of Analgesic Effects between Nalbuphine and Sufentanil in First-Trimester Surgical Abortion: A Randomized, Double-Blind, Controlled Trial. Pain Ther 2021; 11:121-132. [PMID: 34843078 PMCID: PMC8861234 DOI: 10.1007/s40122-021-00334-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/13/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Surgical abortion is one of the commonly conducted procedures worldwide. Nevertheless, pregnant women still complain of procedural and postoperative pain despite the use of advanced anesthesia. It is vital to women’s reproductive healthcare to improve postsurgical pain management to achieve the lowest level of pain. Methods This randomized, double-blind, parallel-controlled clinical trial compared the analgesic effects between nalbuphine and sufentanil in patients who underwent first-trimester surgical abortion. In total, 224 patients were allocated randomly into (a) the sufentanil group that received sufentanil (0.1 ug/kg) combined propofol, and (b) the nalbuphine group that received nalbuphine (0.1 mg/kg) combined propofol. Postoperative pain scores, propofol injection pain, intraoperative analgesic effect, adverse events, and degree of satisfaction were recorded as outcome measures. Results The pain scores in the nalbuphine group were lower than those in the sufentanil group at 15 min, 30 min, 1 h, and 6 h after surgical abortion. In addition, the incidence and intensity of propofol injection pain were lower in the nalbuphine group. The degree of satisfaction of the patients in the nalbuphine group was higher than that in the sufentanil group. The intraoperative analgesic effect, hemodynamic fluctuation, and adverse events were comparable between the two groups. Conclusions Nalbuphine combined with propofol is superior to sufentanil combined with propofol for first-trimester abortion surgeries. Clinical Trial Registration The trial was registered at www.chictr.org.cn, identifier ChiCTR2000040243. Supplementary Information The online version contains supplementary material available at 10.1007/s40122-021-00334-0.
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Affiliation(s)
- Panpan Fang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, People's Republic of China
| | - Jing Qian
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, People's Republic of China
| | - Jianming Ding
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, People's Republic of China
| | - Xiao Pan
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, People's Republic of China
| | - Han Su
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, People's Republic of China
| | - Xuesheng Liu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, People's Republic of China.
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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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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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Hershko Klement A, Frederic M, Bentov Y, Chang P, Nayot D, Haas J, Casper RF. Oral contraceptive pills as an option for non-surgical management of retained products of conception - a preliminary study. Gynecol Endocrinol 2018; 34:609-611. [PMID: 29345165 DOI: 10.1080/09513590.2018.1427714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Many Patients with persistent retained products of conception prefers to avoid surgical interventions, such as a dilatation and curettage (D&C) that might pose an additional future risk to their already compromised fertility or obstetric performance. The aim of this study was to the possibility of induced withdrawal bleeding following oral contraceptive administration as a non-surgical treatment for patients with persistent retained products of conception (RPOC). A retrospective study of patients presenting with retained products of conception (RPOC) after failed expectant management or after treatment with PGE1 was performed. Twelve women presenting with RPOC at ≤8 weeks gestation with minimal to mild vaginal bleeding and no signs of infection were treated with oral contraceptive pill (OCP) containing 0.03 mg ethinylestradiol and 0.15 mg of desogestrel for 3 weeks. Out of the 12 patients treated, nine women (75%) successfully expelled the RPOC after completing the three-week course of OCPs. The three cases (25%) that did not resolve following OCP treatment had pregnancy products with positive blood flow on Doppler examination. We conclude that OCPs may be a useful medical treatment option for persisting RPOC in selected patients with absence blood flow on Doppler examination wishing to avoid surgical intervention.
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MESH Headings
- Abortion, Incomplete/drug therapy
- Abortion, Incomplete/epidemiology
- Abortion, Incomplete/etiology
- Abortion, Induced/adverse effects
- Abortion, Induced/methods
- Abortion, Induced/statistics & numerical data
- Abortion, Spontaneous/drug therapy
- Abortion, Spontaneous/surgery
- Adult
- Choice Behavior
- Contraceptives, Oral, Combined/therapeutic use
- Desogestrel/therapeutic use
- Dilatation and Curettage
- Ethinyl Estradiol/therapeutic use
- Female
- Humans
- Misoprostol/therapeutic use
- Pilot Projects
- Pregnancy
- Pregnancy Trimester, First
- Retrospective Studies
- Tablets
- Treatment Failure
- Uterine Hemorrhage/drug therapy
- Uterine Hemorrhage/epidemiology
- Uterine Hemorrhage/etiology
- Uterine Hemorrhage/surgery
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Affiliation(s)
- Anat Hershko Klement
- a Department of Obstetrics and Gynecology, TRIO Fertility, Toronto and Division of Reproductive Sciences , University of Toronto , Toronto , Canada
- b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Mitri Frederic
- a Department of Obstetrics and Gynecology, TRIO Fertility, Toronto and Division of Reproductive Sciences , University of Toronto , Toronto , Canada
| | - Yaakov Bentov
- a Department of Obstetrics and Gynecology, TRIO Fertility, Toronto and Division of Reproductive Sciences , University of Toronto , Toronto , Canada
| | - Paul Chang
- a Department of Obstetrics and Gynecology, TRIO Fertility, Toronto and Division of Reproductive Sciences , University of Toronto , Toronto , Canada
| | - Dan Nayot
- a Department of Obstetrics and Gynecology, TRIO Fertility, Toronto and Division of Reproductive Sciences , University of Toronto , Toronto , Canada
| | - Jigal Haas
- a Department of Obstetrics and Gynecology, TRIO Fertility, Toronto and Division of Reproductive Sciences , University of Toronto , Toronto , Canada
| | - Robert F Casper
- a Department of Obstetrics and Gynecology, TRIO Fertility, Toronto and Division of Reproductive Sciences , University of Toronto , Toronto , Canada
- b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
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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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Kucherov A, Atrio J, Williams Z. Patient-controlled tissue collection for genetic testing after early pregnancy loss: A pilot study. Prenat Diagn 2018; 38:204-209. [DOI: 10.1002/pd.5215] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 12/15/2017] [Accepted: 01/08/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Alexander Kucherov
- Department of Obstetrics & Gynecology and Women's Health; Albert Einstein College of Medicine, Montefiore Medical Center; Bronx NY USA
| | - Jessica Atrio
- Department of Obstetrics & Gynecology and Women's Health; Albert Einstein College of Medicine, Montefiore Medical Center; Bronx NY USA
| | - Zev Williams
- Department of Obstetrics & Gynecology; Columbia University Medical Center; New York NY USA
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Jones RK, Jerman J. Characteristics and Circumstances of U.S. Women Who Obtain Very Early and Second-Trimester Abortions. PLoS One 2017; 12:e0169969. [PMID: 28121999 PMCID: PMC5266268 DOI: 10.1371/journal.pone.0169969] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 12/24/2016] [Indexed: 11/18/2022] Open
Abstract
Objective To determine which characteristics and circumstances were associated with very early and second-trimester abortion. Methods Paper and pencil surveys were collected from a national sample of 8,380 non-hospital U.S. abortion patients in 2014 and 2015. We used self-reported LMP to calculate weeks gestation; when LMP was not provided we used self-reported weeks pregnant. We constructed two dependent variables: obtaining a very early abortion, defined as six weeks gestation or earlier, and obtaining second-trimester abortion, defined as occurring at 13 weeks gestation or later. We examined associations between the two measures of gestation and a range of characteristics and circumstances, including type of abortion waiting period in the patients’ state of residence. Results Among first-trimester abortion patients, characteristics that decreased the likelihood of obtaining a very early abortion include being under the age of 20, relying on financial assistance to pay for the procedure, recent exposure to two or more disruptive events and living in a state that requires in-person counseling 24–72 hours prior to the procedure. Having a college degree and early recognition of pregnancy increased the likelihood of obtaining a very early abortion. Characteristics that increased the likelihood of obtaining a second-trimester abortion include being Black, having less than a high school degree, relying on financial assistance to pay for the procedure, living 25 or more miles from the facility and late recognition of pregnancy. Conclusions While the availability of financial assistance may allow women to obtain abortions they would otherwise be unable to have, it may also result in delays in accessing care. If poor women had health insurance that covered abortion services, these delays could be alleviated. Since the study period, four additional states have started requiring that women obtain in-person counseling prior to obtaining an abortion, and the increase in these laws could slow down the trend in very early abortion.
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Affiliation(s)
- Rachel K Jones
- Research Division, Guttmacher Institute, New York, New York, United States of America
| | - Jenna Jerman
- Research Division, Guttmacher Institute, New York, New York, United States of America
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Linet T. Interruption volontaire de grossesse instrumentale. ACTA ACUST UNITED AC 2016; 45:1515-1535. [DOI: 10.1016/j.jgyn.2016.09.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 09/26/2016] [Indexed: 11/29/2022]
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