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Lambert SJ, Lunde B, Porsch L, Stoffels G, MacIsaac L, Dayananda I, Dragoman MV. Adjuvant misoprostol or mifepristone for cervical preparation with osmotic dilators before dilation and evacuation. Contraception 2024; 132:110364. [PMID: 38218312 DOI: 10.1016/j.contraception.2024.110364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 01/03/2024] [Accepted: 01/08/2024] [Indexed: 01/15/2024]
Abstract
OBJECTIVES This study aimed to compare effectiveness and safety of cervical preparation with osmotic dilators plus same-day misoprostol or overnight mifepristone prior to dilation and evacuation (D&E). STUDY DESIGN We conducted a retrospective cohort analysis of 664 patients initiating abortion between 18 and 22 weeks at an ambulatory health center. We abstracted medical record data from two consecutive 12-month periods in 2017 to 2019. All patients received overnight dilators plus: 600 mcg buccal misoprostol 90 minutes before D&E (period 1); 200 mg oral mifepristone at time of dilators (period 2). Our primary outcome was procedure time. We report frequency of patients experiencing any acute complication, defined as unplanned procedure (i.e., reaspiration, cervical laceration repair, uterine balloon tamponade) or hospital transfer and bleeding complications. RESULTS We observed higher mean procedure time in the mifepristone group (9.7 ± 5.3 minutes vs 7.9 ± 4.4, p = 0.004). After adjusting for race, ethnicity, insurance, body mass index, parity, prior cesarean, prior uterine surgery, gestational age, provider, trainee participation, and long-acting reversible contraception initiation, the difference remained statistically significant (relative change 1.09, 95% CI 1.01, 1.17) but failed to reach our threshold for clinical significance. The use of additional misoprostol was more common in the mifepristone group, but the use of an additional set of dilators was not different between groups. Acute complications occurred at a frequency of 4.1% in misoprostol group and 4.3% in mifepristone group (p = 0.90). CONCLUSIONS We found procedure time to be longer with adjunctive mifepristone compared to misoprostol; however, this difference is unlikely to be clinically meaningful. Furthermore, the frequency of acute complications was similar between groups. IMPLICATIONS Overnight mifepristone at the time of cervical dilator placement is a safe and effective alternative to adjuvant same-day misoprostol for cervical preparation prior to D&E and may offer benefits for clinic flow and patient experience.
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Affiliation(s)
- Stephanie J Lambert
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Britt Lunde
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lauren Porsch
- Planned Parenthood of Greater New York, New York, NY, USA
| | - Guillaume Stoffels
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Laura MacIsaac
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ila Dayananda
- Planned Parenthood of Greater New York, New York, NY, USA
| | - Monica V Dragoman
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Kerns JL, Brown K, Nippita S, Steinauer J. Society of Family Planning Clinical Recommendation: Management of hemorrhage at the time of abortion. Contraception 2024; 129:110292. [PMID: 37739302 DOI: 10.1016/j.contraception.2023.110292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 09/07/2023] [Accepted: 09/15/2023] [Indexed: 09/24/2023]
Abstract
Hemorrhage after abortion is rare, occurring in fewer than 1% of abortions, but associated morbidity may be significant. Although medication abortion is associated with more bleeding than procedural abortion, overall bleeding for the two methods is minimal and not clinically different. Hemorrhage can be caused by atony, coagulopathy, and abnormal placentation, as well as by such procedure complications as perforation, cervical laceration, and retained tissue. Evidence for practices around postabortion hemorrhage is extremely limited. The Society of Family Planning recommends preoperative identification of individuals at high risk of hemorrhage as well as development of an organized approach to treatment. Specifically, individuals with a uterine scar and complete placenta previa seeking abortion at gestations after the first trimester should be evaluated for placenta accreta spectrum. For those at high risk of hemorrhage, referral to a higher-acuity center should be considered. We propose an algorithm for treating postabortion hemorrhage as follows: (1) assessment and examination, (2) uterine massage and medical therapy, (3) resuscitative measures with laboratory evaluation and possible reaspiration or balloon tamponade, and (4) interventions such as embolization and surgery. Evidence supports the use of oxytocin as prophylaxis for bleeding with dilation and evacuation; methylergonovine prophylaxis, however, is associated with more bleeding at the time of dilation and evacuation. Future research is needed on tranexamic acid as prophylaxis and treatment and misoprostol as prophylaxis. Structural inequities contribute to bleeding risk. Acknowledging how our policies hinder or remedy health inequities is essential when developing new guidelines and approaches to clinical services.
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Affiliation(s)
- Jennifer L Kerns
- University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, USA.
| | - Katherine Brown
- University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, USA
| | - Siripanth Nippita
- New York University, Department of Obstetrics and Gynecology, New York, NY, USA
| | - Jody Steinauer
- University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, USA
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Spingler T, Sonek J, Hoopmann M, Prodan N, Abele H, Kagan KO. Complication rate after termination of pregnancy for fetal defects. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:88-93. [PMID: 36609996 DOI: 10.1002/uog.26157] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/28/2022] [Accepted: 12/21/2022] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To assess the risk of complications in women undergoing termination of pregnancy (TOP) for fetal defects and to examine the impact of gestational age on the complication rate. METHODS This was a retrospective study of women with a singleton pregnancy undergoing TOP at the University Hospital of Tübingen, Germany, between 2018 and 2021. TOP was performed by experienced operators according to the national protocol; dilatation and curettage (D&C) or evacuation (D&E) was used in the first and early second trimesters and induction was used later in pregnancy. The following were considered to be significant procedure-related complications: blood loss of more than 500 mL, uterine perforation, need for blood transfusion, allergic reaction, creation of a false passage (via falsa), systemic infection, readmission to hospital, any unplanned surgical procedure, such as repeat D&C/D&E or hysterectomy, and maternal death. RESULTS The search of the hospital database identified 416 pregnancies that met the study criteria. Median maternal and gestational age at termination were 34.1 years and 17.4 weeks, respectively. In the first, second and third trimesters, respectively, 84 (20.2%), 278 (66.8%) and 54 (13.0%) pregnancies were terminated, for which D&C or D&E was used in 80 (95.2%), 21 (7.6%) and 0 (0.0%) cases. Seventy-seven (18.5%) women had at least one previous Cesarean section and 169 (40.6%) had at least one previous spontaneous delivery. Overall, 95 (22.8%) women had complications during or after TOP. A significantly higher complication rate was noted for terminations performed later in pregnancy. The median gestational age at termination was 16.6 weeks in women who did not experience complications and 20.7 weeks in those with complications (P < 0.001). The respective complication rates in the first, second and third trimesters were 6.0%, 27.0% and 27.8%. CONCLUSION In women undergoing TOP for fetal defects, the risk of complications increases with advancing gestational age. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- T Spingler
- Department of Women's Health, University Hospital of Tübingen, Tübingen, Germany
| | - J Sonek
- Fetal Medicine Foundation USA, Dayton, OH, USA
- Division of Maternal-Fetal Medicine, Wright State University, Dayton, OH, USA
| | - M Hoopmann
- Department of Women's Health, University Hospital of Tübingen, Tübingen, Germany
| | - N Prodan
- Department of Women's Health, University Hospital of Tübingen, Tübingen, Germany
| | - H Abele
- Department of Women's Health, University Hospital of Tübingen, Tübingen, Germany
| | - K O Kagan
- Department of Women's Health, University Hospital of Tübingen, Tübingen, Germany
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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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Second-trimester abortion care for those with complex medical conditions. Curr Opin Obstet Gynecol 2022; 34:359-366. [PMID: 36036465 DOI: 10.1097/gco.0000000000000817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF THE REVIEW This review focuses on patients who are most likely to experience morbidity associated with second trimester abortion care and risk mitigation strategies. RECENT FINDINGS Prior cesarean birth, particularly multiple prior cesarean births, is the most significant risk factor associated with complications during second trimester abortion because of increased risks of hemorrhage, with or without placenta accreta spectrum (PAS), and distorted anatomy, which increases the risk of uterine perforation. Recent data suggests that first trimester ultrasound findings may be predictive of PAS, including multiple lacunae, abnormal uteroplacental interface, and hypervascularity. Multiple common medications interact with mifepristone and are therefore contraindicated; ulipristal shares mifepristone's selective progesterone receptor modulator activity but does not share the same metabolic pathway. Recent data suggests ulipristal may be an effective adjunct for cervical preparation, avoiding potentially mifepristone's drug-drug interactions. Those ending a pregnancy due to severe early-onset hypertensive disorders have a high rate of clinically significant thrombocytopenia: platelet transfusion is recommended for those with platelets <50 000 per cubic millimeter. SUMMARY Pregnant people presenting for care in the second trimester may have conditions that make an abortion more technically or medically complex. Clinicians can mitigate much of this increased risk with preprocedural planning, and appropriate intra-operative preparedness.
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McNamee K, Edelman A, Li RHW, Kaur S, Bateson D. Best Practice Contraception Care for Women with Obesity: A Review of Current Evidence. Semin Reprod Med 2022; 40:246-257. [PMID: 36746158 DOI: 10.1055/s-0042-1760214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The prevalence of obesity among females of reproductive age is increasing globally. Access to the complete range of appropriate contraceptive options is essential for upholding the reproductive rights of this population group. People with obesity can experience stigma and discrimination when seeking healthcare, and despite limited evidence for provider bias in the context of contraception, awareness for its potential at an individual provider and health systems level is essential. While use of some hormonal contraceptives may be restricted due to increased health risks in people with obesity, some methods provide noncontraceptive benefits including a reduced risk of endometrial cancer and a reduction in heavy menstrual bleeding which are more prevalent among individuals with obesity. In addition to examining systems-based approaches which facilitate the provision of inclusive contraceptive care, including long-acting reversible contraceptives which require procedural considerations, this article reviews current evidence on method-specific advantages and disadvantages for people with obesity to guide practice and policy.
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Affiliation(s)
| | - Alison Edelman
- Department of Obstetrics and Gynecology, School of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Raymond Hang Wun Li
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - Simranvir Kaur
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California
| | - Deborah Bateson
- Faculty of Medicine and Health, Daffodil Centre, University of Sydney, Sydney, Australia
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McLaren H, Cancino D, McCulloch M, Wolff S, French V. Rates of complication for dilation and evacuation versus induction of labor in treatment of second trimester intrauterine fetal demise. Eur J Obstet Gynecol Reprod Biol 2022; 277:16-20. [PMID: 35970003 DOI: 10.1016/j.ejogrb.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate clinical differences in the safety of dilation and evacuation (D&E) and induction of labor (IOL) for the treatment of intrauterine fetal demise (IUFD) between 14 and 24 weeks gestation. STUDY DESIGNS A retrospective chart review was conducted at a single institution comparing rates of major and minor complications between patients who undergo D&E and those that undergo IOL in the treatment of IUFD between 14 and 24 weeks gestation. Demographic and medical variables were stratified by management method and analyzed using chi-squared and t-tests where appropriate. RESULTS Patients who underwent IOL were of a more advanced gestational age and more likely to be uninsured. Patients who underwent D&E were more likely to be privately insured. Hospital time for an IOL was significantly longer than for D&E. Composite rates of complication did not differ significantly between management groups. Patients treated with D&E were more likely to require uterine aspiration. CONCLUSIONS D&E and IOL are equally safe methods for the management of IUFD between 14 and 24 weeks gestation. Both options should be made available to patients who experience this rare pregnancy outcome.
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Affiliation(s)
- Hilary McLaren
- Department of Obstetrics and Gynecology, University of Chicago Medicine, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Dominic Cancino
- School of Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Megan McCulloch
- School of Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Sharon Wolff
- Department of Population Health, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA
| | - Valerie French
- Department of Obstetrics and Gynecology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA.
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Uhm S, Mastey N, Baker CC, Chen MJ, Matulich MC, Hou MY, Melo J, Wilson SF, Creinin MD. Mifepristone prior to osmotic dilators for dilation and evacuation cervical preparation: A randomized, double-blind, placebo-controlled pilot study. Contraception 2021; 107:23-28. [PMID: 34464634 DOI: 10.1016/j.contraception.2021.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 08/20/2021] [Accepted: 08/20/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To evaluate mifepristone impact on osmotic dilator placement and procedural outcomes when given 18 to 24 hours before dilator placement for dilation and evacuation (D&E) at 18 weeks 0 days to 23 weeks 6 days gestation. STUDY DESIGN We performed a randomized, double-blind, placebo-controlled trial from April 2019 through February 2021, enrolling participants undergoing osmotic dilator (Dilapan) placement for a planned, next-day D&E. Participants took mifepristone 200 mg or placebo orally 18 to 24 hours before dilator placement. We used a gestational age-based protocol for minimum number of dilators. Our primary outcome was the proportion of participants for whom 2 or more additional dilators could be placed compared to the minimum gestational age-based standard. We secondarily evaluated cervical dilation after dilator removal in the operating room, subjective procedure ease, and complication rates (cervical laceration, uterine perforation, blood transfusion, infection, hospitalization, or extramural delivery). RESULTS Of the planned 66 participants, we enrolled 44 (stopped due to coronavirus disease 2019-related obstacles), and 41 (19 mifepristone; 22 placebo) completed the study. We placed 2 or more additional dilators compared to standard in 7 (36.8%) and 3 (13.6%) participants after mifepristone and placebo, respectively (p = 0.14). We measured greater median initial cervical dilation in the mifepristone (3.2 cm[2.6-3.6]) compared to placebo (2.6 cm[2.2-3.0]) group, p = 0.03. Surgeon's perception of procedure being "easy" (8/19[42.1] vs 9/22[40.9], respectively, p = 1.00) and complication rate (3/19[15.8%] vs 3/22[13.6], respectively, p = 1.00) did not differ. CONCLUSION Our underpowered study did not demonstrate a difference in cervical dilator placement, but mifepristone 18 to 24 hours prior to dilators increases cervical dilation without increasing complications. IMPLICATIONS Mifepristone 18 to 24 hours prior to cervical dilator placement may be a useful adjunct to cervical dilators based on increased cervical dilation at time of procedure; however, logistical barriers, such as an additional visit, may preclude routine adoption without definite clinical benefit.
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Affiliation(s)
- Suji Uhm
- Department of Obstetrics and Gynecology, University of Pittsburgh School of Medicine; Pittsburgh, PA, United States.
| | - Namrata Mastey
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA, United States
| | - Courtney C Baker
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA, United States
| | - Melissa J Chen
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA, United States
| | - Melissa C Matulich
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA, United States
| | - Melody Y Hou
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA, United States
| | - Juliana Melo
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA, United States
| | | | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis; Sacramento, CA, United States
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Liu SM, Flink-Bochacki R. A single-blinded randomized controlled trial evaluating pain and opioid use after dilator placement for second-trimester abortion. Contraception 2021; 103:171-177. [PMID: 33285100 DOI: 10.1016/j.contraception.2020.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/19/2020] [Accepted: 11/25/2020] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To compare pain levels and medication needs after placement of laminaria vs Dilapan-S, and after dilation and evacuation (D&E). STUDY DESIGN We conducted a single-blinded randomized control trial of patients undergoing D&E at 15 0/7 to 23 6/7 weeks gestation, randomizing to cervical preparation with laminaria or Dilapan-S. We compared pain levels and medication usage following dilator placement (5 minutes; 2, 4, and 8 hours; the following morning) and D&E (1, 4, 24, and 48 hours). Our primary outcome was median change from baseline pain, and secondary outcomes included maximum pain timing and overall narcotic use. We compared baseline characteristics, median pain increases and quantities of narcotics used. RESULTS We analyzed 67 participants with laminaria (n = 34) and Dilapan-S (n = 33). More Dilapan-S users had a prior vaginal delivery (n = 20, 60.6%) than laminaria users (n = 11, 32.4%), p = 0.02. Maximum median pain was not statistically different (Laminaria: +3.5 (interquartile range [IQR] +0.5, +6.5); Dilapan-S: +3 (IQR +1, +5); p = 0.42. Thirty-seven (63.8%) participants reported higher levels of pain following dilator placement than D&E. Overall, 26 (42.6%) participants used narcotics during their abortion episode, with no difference in median number of tablets between laminaria (2, range 1-8) and Dilapan-S (4.5, range 1-15) participants (p = 0.34). CONCLUSIONS Median pain increase did not differ in participants receiving laminaria or Dilapan-S for cervical preparation prior to D&E. The majority of patients will use a small amount of narcotics if available. IMPLICATIONS The lack of difference in pain between laminaria and Dilapan-S enhances the applicability of pain intervention research across dilator types. With over half of participants using a small amount of narcotics during their D&E episode, pain management should be individualized to patient needs.
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Affiliation(s)
- Serena M Liu
- Albany Medical Center, Department of Obstetrics & Gynecology, 391 Myrtle Ave. MC-74, Albany, NY 12208, United States
| | - Rachel Flink-Bochacki
- Albany Medical Center, Department of Obstetrics & Gynecology, 391 Myrtle Ave. MC-74, Albany, NY 12208, United States.
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Miscarriage Treatment-Related Morbidities and Adverse Events in Hospitals, Ambulatory Surgery Centers, and Office-Based Settings. J Patient Saf 2021; 16:e317-e323. [PMID: 30516583 PMCID: PMC7678655 DOI: 10.1097/pts.0000000000000553] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of the study was to examine whether miscarriage treatment-related morbidities and adverse events vary across facility types. METHODS A retrospective cohort study compared miscarriage treatment-related morbidities and adverse events across hospitals, ambulatory surgery centers (ASCs), and office-based settings. Data on women who had miscarriage treatment between 2011 and 2014 and were continuously enrolled in their insurance plan for at least 1 year before and at least 6 weeks after treatment were obtained from a large national private insurance claims database. The main outcome was miscarriage treatment-related morbidities and adverse events occurring within 6 weeks of miscarriage treatment. Secondary outcomes were major events and infections. RESULTS A total of 97,374 miscarriage treatments met inclusion criteria. Most (75%) were provided in hospitals, 10% ASCs, and 15% office-based settings. A total of 9.3% had miscarriage treatment-related events, 1.0% major events, and 1.5% infections. In adjusted analyses, there were fewer events in ASCs (6.5%) than office-based settings (9.4%) and hospitals (9.6%), but no significant difference between office-based settings and hospitals. There were no significant differences in major events between ASCs (0.7%) and office-based settings (0.8%), but more in hospitals (1.1%) than ASCs and office-based settings. There were fewer infections in ASCs (0.9%) than office-based settings (1.2%) and more in hospitals (1.6%) than ASCs and office-based settings. In analyses stratified by miscarriage treatment type, the difference between ASCs and office-based settings was no longer significant for miscarriages treated with procedures. CONCLUSIONS Although there seem to be slightly more events in hospitals than ASCs or office-based settings, findings do not support limiting miscarriage treatment to particular settings.
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Low ST, Chen ZE, Cameron S. Women's experiences of self-referral to an abortion service: qualitative study. BMJ SEXUAL & REPRODUCTIVE HEALTH 2021; 47:37-42. [PMID: 32269055 DOI: 10.1136/bmjsrh-2019-200568] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Guidelines from the UK recommend that women should be able to self-refer to abortion services. In 2016, a self-referral system was introduced to the abortion service in Edinburgh, Scotland, as an option for women. Women could telephone a dedicated phone line during office hours and speak to an administrative assistant working in the abortion service who provided them the next available appointment to be seen in the service. This study aimed to evaluate a self-referral service to abortion by investigating its impact on women's experiences of the referral process. METHODOLOGY 21 semistructured interviews of women attending a specialist abortion service in Edinburgh, Scotland, were conducted. Interviews were transcribed verbatim and thematically analysed. The interviews focused on women's experience of the referral process. RESULTS Three main themes arose from the interviews, including reasons for choosing self-referral, experience of self-referral and challenges to using self-referral. Reasons for choosing self-referral were related to convenience, privacy and autonomy. Women found the experience of self-referral to be pleasant, non-judgemental and patient-centred, and self-referral prepared them for the appointment at the specialist abortion service. However, some women felt rushed, and self-referral made them anxious to attend the appointment. Challenges were difficulty with getting through on telephone lines, varying levels of support required for different individuals and awareness about the option of self-referral. CONCLUSION Women valued the option of self-referral. Women felt that the service should be expanded to increase availability,and promoted to women more widely within the community .
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Affiliation(s)
- Shin Thong Low
- The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
| | - Zhong Eric Chen
- Clinical Effectiveness Unit of the FSRH, Chalmers Centre, Edinburgh, UK
| | - Sharon Cameron
- Clinical Effectiveness Unit of the FSRH, Chalmers Centre, Edinburgh, UK
- Sexual and Reproductive Health, NHS Lothian, Edinburgh, UK
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Orlando MS, Vable AM, Holt K, Wingo E, Newmann S, Shapiro BJ, Borne D, Drey EA, Seidman D. Homelessness, housing instability, and abortion outcomes at an urban abortion clinic in the United States. Am J Obstet Gynecol 2020; 223:892.e1-892.e12. [PMID: 32640198 DOI: 10.1016/j.ajog.2020.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/14/2020] [Accepted: 07/02/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Adverse reproductive health outcomes are well documented among people experiencing homelessness or housing instability. Little is known about abortion outcomes among this population. OBJECTIVE This study aimed to investigate the relationship between housing status and abortion outcomes and whether gestational age mediates this relationship. STUDY DESIGN Our sample comprised 1903 individuals who had abortions at an urban clinic in San Francisco, CA, from 2015 to 2017. We defined homelessness or housing instability as a binary exposure, which included staying outside, with friends and/or family, or in a tent, vehicle, shelter, transitional program, or hotel. We evaluated gestational duration of ≥20 weeks as a mediator variable. Our primary outcome was any abortion complication. Logistic regression models were adjusted for age, race, substance use, mental health diagnoses, and previous vaginal and cesarean deliveries. RESULTS Approximately 19% (n=356) of abortions were among people experiencing homelessness or housing instability. Compared with those with stable housing, people experiencing homelessness or housing instability presented later in pregnancy (mean gestational duration, 13.3 vs 9.5 weeks; P<.001) and had more frequent complications (6.5% vs 2.8%; P<.001; odds ratio, 2.2; 95% confidence interval, 1.2-3.9). Adjusting for race, substance use, mental health diagnoses, and previous cesarean deliveries, individuals experiencing homelessness or housing instability were more likely to have abortion complications (odds ratio, 2.3; 95% confidence interval, 1.3-4.0). However, the relationship was attenuated after adjusting for gestational duration (odds ratio, 1.4; 95% confidence interval, 0.7-2.6), suggesting that gestational duration mediates the relationship between housing status and abortion complications. CONCLUSION Patients experiencing homelessness or housing instability presented later in gestation, which seems to contribute to the increased frequency of abortion complications.
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Affiliation(s)
- Megan S Orlando
- Departments of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Anusha M Vable
- Family and Community Medicine, University of California, San Francisco, San Francisco, CA
| | - Kelsey Holt
- Bixby Center for Global Reproductive Health, San Francisco, CA; Family and Community Medicine, University of California, San Francisco, San Francisco, CA
| | - Erin Wingo
- Bixby Center for Global Reproductive Health, San Francisco, CA
| | - Sara Newmann
- Departments of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA; Bixby Center for Global Reproductive Health, San Francisco, CA
| | - Bradley J Shapiro
- Psychiatry, University of California, San Francisco, San Francisco, CA
| | - Deborah Borne
- San Francisco Health Network Transitions Division, San Francisco Department of Public Health, San Francisco, CA
| | - Eleanor A Drey
- Departments of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA; Bixby Center for Global Reproductive Health, San Francisco, CA
| | - Dominika Seidman
- Departments of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA; Bixby Center for Global Reproductive Health, San Francisco, CA.
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Munoz JL, Bishop Cnm E, Reider M, Radeva M, Hsich G, Singh K. Fetal myelomeningocele diagnosed in the antenatal period: Maternal-fetal characteristics and their relationship with pregnancy decision-making. J Neonatal Perinatal Med 2020; 12:399-403. [PMID: 31381533 DOI: 10.3233/npm-180208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Spina bifida is the most common fetal anomaly of the central nervous system, which affects approximately 1:1000 live births in the United States. Myelomeningocele (MMC) is the most common presentation of spina bifida, representing half of these cases. Given the deformation to the spinal cord and the nerve roots, this defect may result in significant morbidity to infants and major life-long disabilities. In this study we aimed to identify maternal and fetal characteristics associated with expectant management or termination of pregnancy in the setting of antenatally diagnosed MMC. We hypothesized that the level of the defect would correlate with patient's decision to continue the pregnancy. METHODS A retrospective cohort analysis was performed with patients who had presented to the Cleveland Clinic Fetal Care Center between 2005-2017. RESULTS Our data showed 36% of patients with antenatal diagnosis of MMC elected for second trimester terminations versus 64% who chose to continue their pregnancy and deliver either by cesarean section or vaginal delivery. Based on ultrasound findings, there were no significant differences between these two groups. Maternal body mass index was significantly higher in those who continued pregnancies (p = 0.036). In addition, the fetal diagnostic methods chosen by patients were significantly different. Those who elected to terminate were more likely to pursue amniocentesis (p = 0.03) and less likely to opt for MRI characterization of the fetus (p = 0.007). CONCLUSION We conclude, in the setting of fetal MMC diagnosed during pregnancy, patients often rely less on the associated ultrasonographic findings. Personal decisions likely influence the choice of other fetal diagnostic modalities. Other than BMI, we did not see an association between maternal factors and decisions regarding second trimester pregnancy termination.
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Affiliation(s)
- J L Munoz
- OB/GYN and Women's Health Institute, Cleveland Clinic, OH, USA
| | - E Bishop Cnm
- OB/GYN and Women's Health Institute, Cleveland Clinic, OH, USA
| | - M Reider
- OB/GYN and Women's Health Institute, Cleveland Clinic, OH, USA
| | - M Radeva
- Department of Quantitative Health Sciences, Cleveland Clinic, OH, USA
| | - G Hsich
- Department of Pediatric Neurology, Cleveland Clinic, Cleveland, OH, USA
| | - K Singh
- OB/GYN and Women's Health Institute, Cleveland Clinic, OH, USA
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Disseminated Intravascular Coagulation and Hemorrhage After Dilation and Evacuation Abortion for Fetal Death. Obstet Gynecol 2020; 134:708-713. [PMID: 31503145 DOI: 10.1097/aog.0000000000003460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the association between fetal death and risk of hemorrhage and disseminated intravascular coagulation (DIC) among women undergoing dilation and evacuation (D&E) procedures. METHODS We conducted a retrospective cohort study of all D&Es at one academic abortion clinic in San Francisco between 2009 and 2013. We abstracted data on fetal death status, demographic characteristics, and complications including hemorrhage and DIC. We examined the risk of hemorrhage and DIC among women with fetal death compared with those without. We conducted unadjusted and adjusted analyses for the outcomes of hemorrhage, DIC, and any complication. RESULTS Among 92 cases of D&E for fetal death and 4,428 cases of D&E for other reasons, hemorrhage occurred in 10% and 7%, respectively (P=.28), and DIC occurred in 2.0% and 0.2% of the fetal death and nonfetal death cohorts (P<.001). In adjusted analysis, fetal death was associated with 2.9 times higher odds of hemorrhage (95% CI 1.4-6.0). In an unadjusted analysis, fetal death was associated with 12.3 times higher odds of DIC (95% CI 2.6-58.6) and 3.0 times higher odds of any complication (95% CI 1.6-5.9). CONCLUSION Women undergoing D&E for fetal death are far more likely to experience DIC and hemorrhage than are women without fetal death, yet the absolute risk is low (2%). Although D&E providers should be prepared for DIC and hemorrhage, we do not recommend any specific preoperative preparation because the vast majority of D&E abortions for fetal death are uncomplicated.
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Maternal and procedural factors associated with estimated blood loss in second trimester surgical uterine evacuation: a retrospective cohort analysis. Int J Obstet Anesth 2020; 43:65-71. [PMID: 32216983 DOI: 10.1016/j.ijoa.2020.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 02/06/2020] [Accepted: 03/01/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Prior studies examining bleeding with uterine evacuation have focused on high-volume centers performing over 1100 procedures annually. The aim of this study was to examine associations between blood loss and patient and procedural characteristics in a center performing fewer than 50 procedures annually. METHODS This retrospective cohort study, with institutional review board approval, utilized procedural codes to identify patients undergoing uterine evacuation procedures between 14 weeks' and 24 weeks' gestational age across a 50-month period. The primary outcome was estimated blood loss; secondary outcomes were hemorrhage, transfusion and hospital re-admission. Associations between blood loss and other variables were examined using linear regression models. RESULTS Charts of 161 women met inclusion criteria. Median estimated blood loss was 400 mL (IQR 300 mL) with 37% of patients having blood loss of ≥500 mL. In univariate analyses, increased blood loss was associated with later gestational age (P <0.001) and pregnancy termination (P <0.001). In a multiple linear regression model, both remained significant. Each one-week increase in gestational age was associated with a 7.1% mean increase in estimated blood loss (95% CI 2.47% to 11.9%; P=0.003). Patients whose uterine evacuation was indicated for pregnancy termination had an 80.6% increase in blood loss compared with those with pre-operative fetal demise (95% CI 37.5% to 137.2%; P <0.001). Rates of peri-operative transfusion and re-admission for bleeding were <4%. CONCLUSION While blood loss may be greater in low volume centers, our transfusion and re-admission rates were low following second trimester uterine evacuation.
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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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Frarey A, Schreiber C, McAllister A, Shaber A, Sonalkar S, Sammel MD, Long JA. Pathways to Abortion at a Tertiary Care Hospital: Examining Obesity and Delays. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2019; 51:35-41. [PMID: 30645011 DOI: 10.1363/psrh.12086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 08/22/2018] [Accepted: 09/18/2018] [Indexed: 06/09/2023]
Abstract
CONTEXT Advancing gestational age can increase the cost of an abortion and is a significant risk factor for complications. While obesity is not associated with increased risks, anecdotal evidence suggests that obese women seeking services at freestanding abortion clinics are often referred for hospital-based care, which can lead to delays. METHODS In 2016, a cross-sectional survey collected data on the experiences of 201 women who had obtained abortions at a hospital-based clinic in Philadelphia; rates of medical complications were determined from hospital records. Multivariable logistic regression analysis was used to assess if obesity was associated with whether patients had been referred from freestanding abortion clinics or reported other paths to care. Differences in wait time and up-front out-of-pocket costs were examined by women's referral status. RESULTS No difference in rates of abortion complications was found between patient groups. Women who were severely obese (body mass index of at least 40 kg/m2 ) were more likely than normal-weight individuals to have been referred from a freestanding abortion clinic (odds ratio, 7.5). The median wait time to get an abortion was 28 days for referred patients and 12 days for others. Multivariable analysis confirmed that referred patients waited twice as long as other patients (rate ratio, 2.0) and paid 66% more in up-front costs. CONCLUSIONS Future research is needed to determine whether obese women seeking abortions are being referred despite evidence that they do not require hospital-based care. If obese women are suffering delays because of referral, strategies to help overcome delay should also be explored.
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Affiliation(s)
- Alhambra Frarey
- Assistant Professor, Department of Obstetrics and Gynecology, The University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Courtney Schreiber
- Associate Professor, Department of Obstetrics and Gynecology, The University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Arden McAllister
- Research Program Manager, Department of Obstetrics and Gynecology, The University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Allison Shaber
- Medical Student, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia
| | - Sarita Sonalkar
- Assistant Professor, Department of Obstetrics and Gynecology, The University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Mary D Sammel
- Professor, Center for Clinical Epidemiology and Biostatistics, The University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Judith A Long
- Professor, Corporal Michael J. Crezenz VA Center for Health Equity Research and Promotion, and Department of Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia
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Roberts SCM, Upadhyay UD, Liu G, Kerns JL, Ba D, Beam N, Leslie DL. Association of Facility Type With Procedural-Related Morbidities and Adverse Events Among Patients Undergoing Induced Abortions. JAMA 2018; 319:2497-2506. [PMID: 29946727 PMCID: PMC6583042 DOI: 10.1001/jama.2018.7675] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Multiple states have laws requiring abortion facilities to meet ambulatory surgery center (ASC) standards. There is limited evidence regarding abortion-related morbidities and adverse events following abortions performed at ASCs vs office-based settings. OBJECTIVE To compare abortion-related morbidities and adverse events at ASCs vs office-based settings. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of women with US private health insurance who underwent induced abortions in an ASC or office-based setting (January 1, 2011-December 31, 2014). Outcomes were abstracted from a large national private insurance claims database during the 6 weeks following the abortion (date of final follow-up, February 11, 2015). EXPOSURES Facility type for abortion (ASCs vs office-based settings, including facilities such as abortion clinics, nonspecialized clinics, and physician offices). MAIN OUTCOMES AND MEASURES The primary outcome was any abortion-related morbidity or adverse event (such as retained products of conception, abortion-related infection, hemorrhage, and uterine perforation) within 6 weeks after an abortion. Two secondary outcomes, both subsets of the primary outcome, were major abortion-related morbidities and adverse events (such as hemorrhages treated with a transfusion, missed ectopic pregnancies treated with surgery, and abortion-related infections that resulted in an overnight hospital admission) and abortion-related infections. RESULTS Among 49 287 women (mean age, 28 years [SD, 7.3]) who had 50 311 induced abortions, (23 891 [47%] first-trimester aspiration, 13 480 [27%] first-trimester medication, and 12 940 [26%] second trimester or later), 5660 abortions (11%) were performed in ASCs and 44 651 (89%) in office-based settings. Overall, 3.33% had an abortion-related morbidity or adverse event; 0.32% had a major abortion-related morbidity or adverse event; and 0.74% had an abortion-related infection. In adjusted analyses, there was no statistically significant difference between ASCs vs office-based settings, respectively, in the rates of abortion-related morbidities or adverse events (3.25% vs 3.33%, difference, -0.08%; [corrected] 95% CI, -0.58% to 0.43%; adjusted OR, 0.97; 95% CI, 0.81-1.17), major morbidities or adverse events (0.26% vs 0.33%; difference, -0.06%; 95% CI, -0.18% to 0.06%; adjusted OR, 0.78; 95% CI, 0.45-1.37), or infections (0.58% vs 0.77%; difference, -0.16%; 95% CI, -0.35% to 0.03%; adjusted OR, 0.75; 95% CI, 0.52-1.09). CONCLUSIONS AND RELEVANCE Among women with private health insurance who had an induced abortion, performance of the abortion in an ambulatory surgical center compared with an office-based setting was not associated with a significant difference in abortion-related morbidities and adverse events. These findings, in addition to individual patient and individual facility factors, may inform decisions about the type of facility in which induced abortions are performed.
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Affiliation(s)
- Sarah C. M. Roberts
- 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
| | - Ushma D. Upadhyay
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Guodong Liu
- Center for Applied Studies in Health Economics, Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Jennifer L. Kerns
- Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Djibril Ba
- Center for Applied Studies in Health Economics, Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Nancy Beam
- 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
| | - Douglas L. Leslie
- Center for Applied Studies in Health Economics, Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
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Upadhyay UD, Johns NE, Barron R, Cartwright AF, Tapé C, Mierjeski A, McGregor AJ. Abortion-related emergency department visits in the United States: An analysis of a national emergency department sample. BMC Med 2018; 16:88. [PMID: 29898742 PMCID: PMC6000974 DOI: 10.1186/s12916-018-1072-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/10/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Media depictions and laws passed in state legislatures regulating abortion suggest abortion-related medical emergencies are common. An accurate understanding of abortion-related emergencies is important for informing policy and practice. We assessed the incidence of abortion-related emergency department (ED) visits in the United States (U.S.). METHODS We used a retrospective observational study design using 2009-2013 data from the Nationwide Emergency Department Sample, a nationally representative sample of U.S. ED visits from 947 to 964 hospitals across the U.S. per year. All ED visits among women of reproductive age (15-49) were included. We categorized ED visits by abortion relatedness and treatments received, and assessed whether the visit was for a major incident (defined as requiring blood transfusion, surgery, or overnight inpatient stay). We estimated the proportion of visits that were abortion-related and described the characteristics of patients making these visits, the diagnoses and subsequent treatments received by these patients, the sociodemographic and hospital characteristics associated with the incidents and observation care only (defined as receiving no treatments), and the rate of major incidents for all abortion patients in the U.S. RESULTS Among all ED visits by women aged 15-49 (189,480,685), 0.01% (n = 27,941) were abortion-related. Of these visits, 51% (95% confidence interval, 95% CI 49.3-51.9%) of the women received observation care only. A total of 20% (95% CI 19.3-21.3%) of abortion-related ED visits were for major incidents. One-fifth (22%, 95% CI 20.9-23.0%) of abortion-related visits resulted in admission to the same hospital for abortion-related reasons. Of the visits, 1.4% (n = 390, 95% CI 1.1-1.7%) were potentially due to attempts at self-induced abortion. In multivariable models, women using Medicaid (adjusted odds ratio, AOR 1.28, 95% CI 1.08-1.52) and women with a comorbid condition (AORs 2.47-4.63) had higher odds of having a major incident than women using private insurance and those without comorbid conditions. During the study period, 0.11% of all abortions in the U.S. resulted in major incidents as seen in EDs. CONCLUSIONS Abortion-related ED visits comprise a small proportion of women's ED visits. Many abortion-related ED visits may not be indicated or could have been managed at a less costly level of care. Given the low rate of major incidents, perceptions that abortion is unsafe are not based on evidence.
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Affiliation(s)
- Ushma D Upadhyay
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, California, 94612, USA.
| | - Nicole E Johns
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, California, 94612, USA
| | - Rebecca Barron
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Alice F Cartwright
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, California, 94612, USA
| | - Chantal Tapé
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Alyssa Mierjeski
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Alyson J McGregor
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
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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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Lohr PA, Parsons JH, Taylor J, Morroni C. Outcomes of dilation and evacuation with and without feticide by intra-cardiac potassium chloride injection: a service evaluation. Contraception 2018; 98:S0010-7824(18)30146-X. [PMID: 29680767 DOI: 10.1016/j.contraception.2018.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 04/12/2018] [Accepted: 04/15/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To compare procedure duration, complications, and acceptability of dilation and evacuation (D&E) with and without feticide by intra-cardiac potassium chloride (KCL) injection. STUDY DESIGN We evaluated outcomes with D&E at 18-24 weeks of gestation in the 6 months before and 6 months after removing feticide with KCL from the guidelines of a national British abortion provider. We extracted demographic and procedure-related data from medical records and electronic databases. We surveyed women undergoing D&E in both time periods about acceptability and side effects. RESULTS We analyzed 291 cases with and 257 cases without KCL. Unadjusted mean procedure duration was shorter with KCL than without (12.7 vs. 16.1 min, respectively, p<.001). After adjustment for age, parity, Cesarean deliveries, gestational age, body mass index, surgeon, and number or duration of osmotic dilators used, KCL remained associated with a 3.5 min (95% CI 2.4-4.6) reduction in D&E duration. Uterine atony was more common with KCL than without (3% vs. 0%, respectively, p=.004), despite more frequent administration of prophylactic utero-tonics to women who received KCL (82% KCL vs. 73% no-KCL, p=.001). Women who had KCL reported more pain in the period between feticide and dilator placement and the evacuation than women who had not received feticide (49% vs. 25%, respectively, p<.001). Most women in both groups found their procedure very acceptable or acceptable (79% KCL vs. 87% no-KCL, p=.2). CONCLUSIONS Feticide with intra-cardiac KCL reduced D&E procedure duration, but was associated with more pain and uterine atony. Treatment acceptability was high with and without feticide. IMPLICATIONS Inducing fetal demise before dilation and evacuation with intra-cardiac potassium chloride may result in shorter operative times but does not appear to improve safety or acceptability. Level I evidence remains needed to support the use of feticide before surgical abortion.
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Affiliation(s)
| | | | | | - Chelsea Morroni
- Liverpool School of Tropical Medicine, Liverpool, UK; University of Witwatersand Reproductive Health and HIV Institute, Johannesburg; Botswana UPenn Partnership, Gaborone, Botswana
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White KO, Jones HE, Shorter J, Norman WV, Guilbert E, Lichtenberg ES, Paul M. Second-trimester surgical abortion practices in the United States. Contraception 2018; 98:S0010-7824(18)30140-9. [PMID: 29665357 DOI: 10.1016/j.contraception.2018.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 03/31/2018] [Accepted: 04/04/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To assess whether second-trimester surgical abortion practices of U.S. providers agree with evidence-based policy guidelines. STUDY DESIGN We conducted a cross-sectional survey of abortion facilities in the U.S. identified via publicly available resources and professional networks from June through December 2013. RESULTS Of 703 identified facilities, 383 (54%) participated, including 172 clinicians providing second-trimester surgical abortions (dilation and evacuations [D&Es]). The majority of clinicians were obstetrician-gynecologists (87%), female (67%), and less than 50 years old (62%). Most clinicians (93%) ever use misoprostol as a cervical preparation agent, including in the setting of a uterine scar (87%). Some clinicians refer to a hospital-based provider if the patient has a placenta previa and a history of cesarean section (31%) or a complete previa alone (17%). Many clinicians have weight or body mass index restrictions for cases performed under iv moderate sedation (32/97, 33%) or deep sedation (23/50, 46%). Most clinicians (69%) who report performing D&Es at 18 weeks last menstrual period or greater do not routinely induce fetal demise preoperatively. Clinicians employ routine intraoperative ultrasound (79%) more commonly than routine postoperative ultrasound (47%), with no difference by years of provider experience. Most clinicians routinely use prophylactic uterotonic agents, most often postoperatively. Most clinicians (80%) routinely give perioperative antibiotics, most often doxycycline (75%). CONCLUSION Overall, the second-trimester surgical abortion practices revealed in our survey agree with professional evidence-based policy guidelines. Wider variability was reported for practices lacking a strong evidence base. IMPLICATIONS In this third cross-sectional survey of U.S. abortion practices (prior 1997 and 2002), second-trimester surgical abortion providers are younger than before, reflecting an improvement in the "graying" of the abortion provider workforce. Facility restrictions on gestational age along with hospital restrictions on referrals pose barriers to outpatient abortion access.
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Affiliation(s)
- Katharine O White
- Boston Medical Center/Boston University, 850 Harrison Avenue, Dowling 4402, Boston, MA, 02118, USA.
| | - Heidi E Jones
- City University of New York Graduate School of Public Health & Health Policy, 2180 Third Avenue, New York, NY 10035, USA.
| | - Jade Shorter
- Boston Medical Center/Boston University, 850 Harrison Avenue, Dowling 4402, Boston, MA, 02118, USA.
| | - Wendy V Norman
- University of British Columbia, 320-5950 University Blvd, Vancouver, Canada, V6T 1Z3.
| | - Edith Guilbert
- Institut National de Santé Publique du Québec, 945, avenue Wolfe, Québec, Canada, G1V 5B3.
| | - E Steve Lichtenberg
- Family Planning Medical Associates Medical Group, Limited, 659 West Washington Boulevard, Chicago, IL 60661, USA.
| | - Maureen Paul
- Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.
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Mark KS, Bragg B, Talaie T, Chawla K, Murphy L, Terplan M. Risk of complication during surgical abortion in obese women. Am J Obstet Gynecol 2018; 218:238.e1-238.e5. [PMID: 29074080 DOI: 10.1016/j.ajog.2017.10.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/11/2017] [Accepted: 10/16/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Surgical abortion is a generally safe procedure. Obesity is a known risk factor for complications in other surgical procedures, but insufficient information exists to determine the effects of increasing body mass index on the risk of surgical abortions. OBJECTIVE The purpose of this study was to determine whether obesity is a risk factor for major complications in surgical abortions. METHODS A quality control database from a single outpatient center was analyzed to determine rates of major complications during surgical abortions in relation to obesity class. Complications included hemorrhage, need for repeat evacuation, uterine perforation, cervical laceration, medication reaction, unexpected surgery, or unplanned admission to the hospital. Chi-squared and analysis of variance were used for analysis. RESULTS We included 2468 procedures: 1475 procedures (59.8%) in the first trimester and 993 procedures (40.2%) in the second trimester. The overall complications rate was 2.2%. Second-trimester procedures were more likely than those in the first trimester to have complications (3.1% vs 1.6%; P=.009). Overall, 39.6% of the women were obese, and 9.6% of them met criteria for class 3 obesity (body mass index, >40 kg/m2). Women who underwent second-trimester abortions with class 3 obesity had a rate of complication of 8.7%, which was significantly more than normal weight women (odds ratio, 5.90; 95% confidence interval, 1.93-8.07; P<.001). COMMENT Surgical abortions are overall safe procedures, but class 3 obesity increases the rate of complication in second-trimester procedures.
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Anesthesia for Medical Termination of Pregnancy. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Retrospective Evaluation of the Procedural Sedation Practices of Expert Nurses During Abortion Care. J Obstet Gynecol Neonatal Nurs 2017; 46:755-763. [PMID: 28727994 DOI: 10.1016/j.jogn.2017.06.003] [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] [Accepted: 06/01/2017] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate the provision of procedural sedation during abortion by expert nurses and to describe the factors that are associated with time to discharge for women who receive this sedation. DESIGN Retrospective chart review. METHODS Descriptive statistics were generated to describe a retrospective cohort of women presenting for abortion under procedural sedation. Analysis of variance was used to determine significant characteristics that influenced time to discharge. SETTING A single clinical site that employs seven expert nurses. PARTICIPANTS A total of 194 medical records were available for this analysis. RESULTS All women were discharged home with accompaniment, and no incidents of respiratory distress or other adverse complications occurred. Most women (n = 136) received at least 150 μg fentanyl and 3 mg midazolam, and 71% of women in the first trimester and 83% of women in the second trimester entered the recovery area with no pain. Variables significantly associated with time spent in the recovery area were gestational age at time of abortion (t = -2.68, p = .008), pain at entry to recovery area (t = -0.254, p = .008), and pain at 15 minutes (t = 0.25, p = .038). CONCLUSION Expert nurses can administer procedural sedation for pain control associated with abortion and are capable of monitoring women and helping them return to baseline status after the procedure.
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Safety of Outpatient Surgical Abortion for Obese Patients in the First and Second Trimesters. Obstet Gynecol 2017; 128:1065-1070. [PMID: 27741198 DOI: 10.1097/aog.0000000000001692] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To evaluate the relationship between obesity and surgical abortion complications in the outpatient setting. METHODS We conducted a retrospective cohort study of 4,968 women undergoing surgical abortion at a large outpatient clinic network from September 2012 to July 2014. We used log-binomial regression to evaluate body mass index (BMI) as an independent risk factor for first- and second-trimester abortion complications. Body mass index was analyzed as both a continuous and categorical predictor. We assessed complications including need for uterine reaspiration (including same-day reaspiration), uterine perforation, cervical laceration, infection, emergency department visit or hospitalization, and excessive blood loss defined as estimated blood loss greater than or equal to 100 mL. RESULTS The majority (77%) of procedures was performed in the first trimester. Forty-seven percent of women were normal weight or underweight, 28% were overweight, and 25% were obese, including 4% with BMI greater than or equal to 40. The overall complication rate was 1.7%; the most common complications were need for uterine reaspiration (1.0%) and excessive blood loss (0.6%). Obesity was not associated with increased risk of surgical complications, including when adjusting for age, gestational age, and history of prior cesarean delivery. CONCLUSION In a high-volume outpatient abortion clinic with experienced health care providers, abortion is very safe. Obesity does not appear to be an independent predictor for abortion complications and should not be used in isolation to refer women to hospital-based facilities for abortion care in the first or second trimester.
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Whitehouse K, Tschann M, Davis J, Soon R, Salcedo J, Friedlander E, Kaneshiro B. Association between prophylactic oxytocin use during dilation and evacuation and estimated blood loss. Contraception 2017; 96:19-24. [PMID: 28483553 DOI: 10.1016/j.contraception.2017.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/24/2017] [Accepted: 04/27/2017] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Some providers use oxytocin during dilation and evacuation (D&E) to prevent or treat hemorrhage, although evidence to support this is scarce. We sought to describe the association between prophylactic oxytocin use, estimated blood loss (EBL), and surgical outcomes during D&E. STUDY DESIGN We performed a chart review of 730 women at 14 to 26 weeks' gestation who had a D&E at our institution between May 2010 and May 2014 to assess the association between prophylactic oxytocin use and EBL. We determined whether sociodemographic and health-related factors were associated with excessive blood loss (EBL≥250 mL) and whether oxytocin use was associated with complications, including hemorrhage (i.e., EBL≥500 mL or interventions for bleeding). We performed univariate analyses and multivariable regression models to evaluate the relationship between health-related factors and EBL≥250 mL. RESULTS Providers used prophylactic oxytocin in 59.9% of procedures. Asian (p=.005 and Native Hawaiian/Pacific Islander (p=.005) race, nulliparity (p=.007) and higher gestational age (p<.001) were associated with prophylactic oxytocin use. We found no difference in mean EBL (116.2±105.5 mL versus 130.7±125.5 mL, p=.09), EBL≥250 mL (31.4% vs. 68.6%, p=.15) or complications (6.1% vs. 7.1%, p=.73) including hemorrhage (1.4% vs. 5.3%, p=.14) between those who did not receive prophylactic oxytocin and those who did. No transfusions occurred in either group. In multivariable regression modeling, the adjusted OR for excessive blood loss was 0.42 (95% confidence interval 0.16-1.07) with prophylactic oxytocin use. CONCLUSIONS Prophylactic oxytocin use during D&E was not associated with hemorrhage or transfusion in our population. IMPLICATIONS Routine use of interventions for bleeding, such as intravenous oxytocin, should be based on scientific evidence or not performed. Findings from our study provide information on how oxytocin use is associated with blood loss during D&E.
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Affiliation(s)
- Katherine Whitehouse
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou Street, Ste 824, Honolulu, HI 96826
| | - Mary Tschann
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou Street, Ste 824, Honolulu, HI 96826
| | - James Davis
- University of Hawaii, John A. Burns School of Medicine, Department of Biostatistics & Data Management, 651 Ilalo Street, Biosciences Building, Ste 211, Honolulu, HI 96813
| | - Reni Soon
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou Street, Ste 824, Honolulu, HI 96826
| | - Jennifer Salcedo
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou Street, Ste 824, Honolulu, HI 96826
| | - EmmaKate Friedlander
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou Street, Ste 824, Honolulu, HI 96826
| | - Bliss Kaneshiro
- University of Hawaii, John A. Burns School of Medicine, Department of Obstetrics, Gynecology & Women's Health, 1319 Punahou Street, Ste 824, Honolulu, HI 96826.
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