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Gilmore EV, Russell LB, Harvie HS, Schreiber CA. Estimating the cost of Rh testing and prophylaxis in early pregnancy: A time-driven activity-based costing study. Contraception 2024; 136:110468. [PMID: 38648923 DOI: 10.1016/j.contraception.2024.110468] [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: 08/30/2023] [Revised: 04/07/2024] [Accepted: 04/15/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE To estimate the cost of Rhesus (Rh) testing and prophylaxis for first-trimester vaginal bleeding in the ambulatory setting. STUDY DESIGN We used time-driven, activity-based costing to analyze tasks associated with Rh testing and prophylaxis of first-trimester vaginal bleeding at one hospital-based outpatient and two independent reproductive health clinics. At each site, we observed 10 patients undergoing Rh-typing and two patients undergoing Rh prophylaxis. We computed the costs of blood Rh-typing by both fingerstick and phlebotomy, cost of locating previous blood type in the electronic health record (available for 69.8% of hospital-based patients), and costs associated with Rh immune globulin prophylaxis. All costs are reported in 2021 US dollars. RESULTS The hospital-based clinic reviewed the electronic health record to confirm Rh-status (cost, $26.18 per patient) and performed a phlebotomy, at $47.11 per patient, if none was recorded. The independent clinics typed blood by fingerstick, at a per-patient cost of $4.07. Rh-immune globulin administration costs, including the medication, were similar across facilities, at a mean of $145.66 per patient. Projected yearly costs for testing and prophylaxis were $55,831 for the hospital-based clinic, which was the lowest-volume site, $47,941 for Clinic A, which saw 150 patients/month, and $185,654 for Clinic B, which saw 600 patients/month. CONCLUSIONS Rh testing and prophylaxis for first-trimester vaginal bleeding generates considerable costs for outpatient facilities, even for Rh-positive patients with a prior blood type on record. IMPLICATIONS Rh testing and prophylaxis for first-trimester bleeding generate considerable costs even for Rh-positive patients and those with a previously known blood type. These findings highlight the need to reconsider this practice, which is no longer supported by evidence and already safely waived in multiple medical settings in the United States and around the world.
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Affiliation(s)
- Emma V Gilmore
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States.
| | - Louise B Russell
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| | - Heidi S Harvie
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| | - Courtney A Schreiber
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
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Grossman D, Raifman S, Morris N, Arena A, Bachrach L, Beaman J, Biggs MA, Collins A, Hannum C, Ho S, Seibold-Simpson SM, Sobota M, Tocce K, Schwarz EB, Gold M. Mail-Order Pharmacy Dispensing of Mifepristone for Medication Abortion After In-Person Screening. JAMA Intern Med 2024; 184:873-881. [PMID: 38739404 PMCID: PMC11091818 DOI: 10.1001/jamainternmed.2024.1476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/07/2024] [Indexed: 05/14/2024]
Abstract
Importance Before 2021, the US Food and Drug Administration required mifepristone to be dispensed in person, limiting access to medication abortion. Objective To estimate the effectiveness, acceptability, and feasibility of dispensing mifepristone for medication abortion using a mail-order pharmacy. Design, Setting, and Participants This prospective cohort study was conducted from January 2020 to May 2022 and included 11 clinics in 7 states (5 abortion clinics and 6 primary care sites, 4 of which were new to abortion provision). Eligible participants were seeking medication abortion at 63 or fewer days' gestation, spoke English or Spanish, were age 15 years or older, and were willing to take misoprostol buccally. After assessing eligibility for medication abortion through an in-person screening, mifepristone and misoprostol were prescribed using a mail-order pharmacy. Patients had standard follow-up care with the clinic. Clinical information was collected from medical records. Consenting participants completed online surveys about their experiences 3 and 14 days after enrolling. A total of 540 participants were enrolled; 10 withdrew or did not take medication. Data were analyzed from August 2022 to December 2023. Intervention Mifepristone, 200 mg, and misoprostol, 800 µg, prescribed to a mail-order pharmacy and mailed to participants instead of dispensed in person. Main Outcomes and Measures Proportion of patients with a complete abortion with medications only, reporting satisfaction with the medication abortion, and reporting timely delivery of medications. Results Clinical outcome information was obtained and analyzed for 510 abortions (96.2%) among 506 participants (median [IQR] age, 27 [23-31] years; 506 [100%] female; 194 [38.3%] Black, 88 [17.4%] Hispanic, 141 [27.9%] White, and 45 [8.9%] multiracial/other individuals). Of these, 436 participants (85.5%; 95% CI, 82.2%-88.4%) received medications within 3 days. Complete abortion occurred after medication use in 499 cases (97.8%; 95% CI, 96.2%-98.9%). There were 24 adverse events (4.7%) for which care was sought for medication abortion symptoms; 3 patients (0.6%; 95% CI, 0.1%-1.7%) experienced serious adverse events requiring hospitalization (1 with blood transfusion); however, no adverse events were associated with mail-order dispensing. Of 477 participants, 431 (90.4%; 95% CI, 87.3%-92.9%) indicated that they would use mail-order dispensing again for abortion care, and 435 participants (91.2%; 95% CI, 88.3%-93.6%) reported satisfaction with the medication abortion. Findings were similar to those of other published studies of medication abortion with in-person dispensing. Conclusions and Relevance The findings of this cohort study indicate that mail-order pharmacy dispensing of mifepristone for medication abortion was effective, acceptable to patients, and feasible, with a low prevalence of serious adverse events. This care model should be expanded to improve access to medication abortion services.
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Affiliation(s)
- Daniel Grossman
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Sarah Raifman
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Natalie Morris
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Andrea Arena
- Department of Family Medicine, Brown University, Pawtucket, Rhode Island
| | - Lela Bachrach
- Department of Pediatrics, University of California, San Francisco
| | - Jessica Beaman
- Division of General Internal Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
| | - M. Antonia Biggs
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Amy Collins
- Allegheny Reproductive Health Center, Pittsburgh, Philadelphia
| | | | - Stephanie Ho
- Highland Hospital, Alameda Health System, Oakland, California
| | | | - Mindy Sobota
- Department of Medicine, Alpert Medical School at Brown University, Providence, Rhode Island
| | - Kristina Tocce
- Planned Parenthood of the Rocky Mountains, Denver, Colorado
| | - Eleanor B. Schwarz
- Division of General Internal Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco
| | - Marji Gold
- Department of Family and Social Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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Kerestes C, Tschann M, Pearlman Shapiro M, Berry E, Gawron L, Soon R, Kaneshiro B. Self-Determination of Eligibility for Medication Abortion Without Ultrasonography Using a History-Based Tool: LMP-SURE. Obstet Gynecol 2024:00006250-990000000-01117. [PMID: 39053008 DOI: 10.1097/aog.0000000000005675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 05/23/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVE To evaluate a self-screening eligibility tool for medication abortion without an ultrasonogram. METHODS We designed a patient-administered, five-question screening tool (LMP-SURE) that assesses gestational age plus factors associated with misdating or ectopic pregnancy. We recruited participants without prior ultrasonograms from family planning clinics in Alaska, Hawai'i, Idaho, and Utah to complete a brief survey including LMP-SURE and then obtained ultrasound dating by chart review. We compared eligibility for medication abortion by ultrasonogram with eligibility by the LMP-SURE screening tool. RESULTS We consented 1,026 participants; 781 met eligibility requirements and completed the tool. Using the LMP-SURE tool, we identified 493 participants (65.1%) eligible for medication abortion without an ultrasonogram. The LMP-SURE tool sensitivity (ability to correctly identify a patient ineligible for medication abortion) was 83.8% (95% CI, 73.1-90.8), specificity (ability to correctly identify a patient eligible for medication abortion) was 70.0% (95% CI, 66.4-73.3), likelihood ratio (-) (probability of someone eligible by LMP-SURE to be ineligible by ultrasonogram vs eligible by ultrasonogram) was 0.23 (95% CI, 0.13-0.40), and percentage of false-negatives was 1.5%. Only 11 patients (1.5%) who met eligibility for medication abortion without an ultrasonogram by the LMP-SURE tool were found ineligible for medication abortion by their ultrasonogram. Of those with conflicts, six (0.8%) had a gestational age beyond 77 days. The two participants (0.3%) diagnosed with ectopic pregnancies both required ultrasonograms by LMP-SURE. CONCLUSION This patient-facing, brief, history-based screening tool can safely minimize the need for ultrasonogram before medication abortion.
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Affiliation(s)
- Courtney Kerestes
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio; the Department of Obstetrics, Gynecology, and Women's Health, University of Hawai'i, Honolulu, Hawai'i; the Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California; Planned Parenthood Great Northwest, Hawai'i, Alaska, Indiana, Kentucky, Seattle, Washington; and the Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
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Turner JV, Garratt D, Barwick A, McLindon LA, Spark MJ, Smith A. Congenital and Fetal Effects After Mifepristone Exposure and Continuation of Pregnancy: A Systematic Review. Clin Pharmacol Ther 2024. [PMID: 39049612 DOI: 10.1002/cpt.3392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 07/09/2024] [Indexed: 07/27/2024]
Abstract
Mifepristone is an anti-progestational drug that is the first component of the standard medical abortion regimen. For women who take mifepristone and then do not take misoprostol, which is the second component of the medical abortion regimen, it is possible that their pregnancy may continue to live birth. Since mifepristone is commonly used for medical abortion up to 9-10 weeks gestation, any adverse or teratogenic effects on the developing embryo/fetus must be considered, given exposure during the critical time of its development and organogenesis. Toxicology and teratology reports have cited studies demonstrating teratogenic effect of mifepristone in some animals. Current clinical guidelines for women exposed to mifepristone in the first trimester of pregnancy state that it is not known to be teratogenic based on limited published evidence from humans. The aim of this narrative systematic review was to investigate embryonic/fetal exposure to mifepristone and any association with congenital or fetal anomalies. This study was conducted by systematic searches of health databases from inception to February 2024. The references of relevant citations were manually searched to retrieve any additional citations not captured in database searching. Congenital anomalies and adverse outcomes were encountered at various doses of mifepristone exposure. A number of the congenital anomalies encountered in this review were explained by circumstances other than exposure to mifepristone. The present systematic review did not find data to support mifepristone being implicated as a teratogen.
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Affiliation(s)
- Joseph V Turner
- School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Deborah Garratt
- School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
| | - Anna Barwick
- School of Health-Pharmacy, University of New England, Armidale, New South Wales, Australia
| | - Lucas A McLindon
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - M Joy Spark
- School of Health-Pharmacy, University of New England, Armidale, New South Wales, Australia
| | - Angela Smith
- Hunter New England Local Health District, NSW Health, Newcastle, New South Wales, Australia
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Carroll AL, Strauss AM, Philipps NM, Kaczmarczik KD, Shakur Z, Ramirez G, Klc TR, Tessier KM, Boraas CM. Efficacy of medication abortion with concurrent initiation of progestin contraceptives: A retrospective cohort study. Contraception 2024:110536. [PMID: 38986862 DOI: 10.1016/j.contraception.2024.110536] [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: 04/09/2024] [Revised: 06/27/2024] [Accepted: 07/05/2024] [Indexed: 07/12/2024]
Abstract
OBJECTIVES To evaluate medication abortion (MAB) outcomes for participants receiving intramuscular depot medroxyprogesterone acetate (DMPA) injections or subdermal etonogestrel implants concurrently with mifepristone compared to those who did not in a real-world setting. STUDY DESIGN This retrospective cohort study included MAB patients from one Planned Parenthood health center in St. Paul, MN, between 2017 and 2019. We abstracted electronic health records and compared sociodemographic variables, clinical information, and treatment failure rates (primary outcome) between study groups with logistic regression (generating odds ratios [OR] and 95% confidence intervals [CI]). RESULTS Among 7296 MAB participants, 224 (3.1%) received DMPA injections and 309 (4.2%) received etonogestrel implants concurrently with mifepristone; 141 (62.9%) and 200 (64.7%) completed follow-up respectively. From a random sample of 1000, 990 comparison participants met inclusion criteria; 704 (71.1%) completed follow-up. Fourteen (9.9%) DMPA participants (aOR 4.26, 95% CI 1.87-9.68, p < 0.001) and 6 (3.0%) etonogestrel implant participants (aOR 1.38, 95% CI 0.48-3.55, p = 0.522) required additional treatment to empty the uterus and/or had an ongoing pregnancy, each contrasted with 15 (2.1%) comparison patients (models adjusted for gestational duration, patient age, parity, and race). CONCLUSION Although our study is limited by high rates of loss to follow-up, our analysis suggests that concurrent administration of DMPA with mifepristone may decrease MAB efficacy, while etonogestrel implant placement does not appear to alter MAB outcomes. These findings are overall consistent with prior literature and inform post-MAB contraception counseling. IMPLICATIONS This retrospective cohort study reinforces prior randomized controlled trial findings that concurrent depot medroxyprogesterone acetate injection with mifepristone administration may decrease medication abortion efficacy. Conversely, concurrent etonogestrel contraceptive implant placement with mifepristone administration does not appear to decrease medication abortion efficacy. These findings inform post-abortion contraception counseling.
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Affiliation(s)
- Anna L Carroll
- Department of Obstetrics, Gynecology & Women's Health, University of Minnesota, Minneapolis, MN, United States.
| | - Anna M Strauss
- Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Nicole M Philipps
- Medical School, University of Minnesota, Minneapolis, MN, United States
| | | | - Zahrah Shakur
- Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Gerardo Ramirez
- Medical School, University of Minnesota, Minneapolis, MN, United States
| | - Tenley R Klc
- Department of Obstetrics, Gynecology & Women's Health, University of Minnesota, Minneapolis, MN, United States
| | - Katelyn M Tessier
- Masonic Cancer Center, Biostatistics Core, University of Minnesota, Minneapolis, MN, United States
| | - Christy M Boraas
- Department of Obstetrics, Gynecology & Women's Health, University of Minnesota, Minneapolis, MN, United States; Research Division, Planned Parenthood North Central States, St. Paul, MN, United States
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Chen J, Nijim S, Koelper N, Flynn AN, Sonalkar S, Schreiber CA, Roe AH. Telemedicine Follow-up After Medication Management of Early Pregnancy Loss. J Womens Health (Larchmt) 2024. [PMID: 38959113 DOI: 10.1089/jwh.2023.0795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024] Open
Abstract
Objective: Our objective was to evaluate the feasibility of a new protocol for telemedicine follow-up after medication management of early pregnancy loss. Study Design: The study was designed to assess the feasibility of planned telemedicine follow-up after medication management of early pregnancy loss. We compared these follow-up rates with those after planned in-person follow-up of medication management of early pregnancy loss and planned telemedicine follow-up after medication abortion. We conducted a retrospective cohort study, including patients initiating medication management of early pregnancy loss <13w0d gestation and medication abortion ≤10w0d with a combination of mifepristone and misoprostol between April 1, 2020, and March 28, 2021. As part of a new clinical protocol, patients could opt for telemedicine follow-up one week after treatment and a home urine pregnancy test 4 weeks after treatment. Our primary outcome was completed follow-up as per clinical protocol. We also examined outcomes related to complications across telemedicine and in-person follow-up groups. Results: Of patients reviewed, 181 were eligible for inclusion; 75 had medication management of early pregnancy loss, and 106 had medication abortion. Thirty-six out of 75 patients elected for telemedicine follow-up after early pregnancy loss. Of patients scheduled for telemedicine follow-up, 29/36 (81%, 95% CI: 64-92) with early pregnancy loss and 64/69 (93%, 95% CI: 84-98) undergoing medication abortion completed follow-up as per protocol (p = 0.06). Completed follow-up was also similar among patients undergoing medication management of early pregnancy loss who planned for in-person follow-up (p = 0.135). Complications were rare and did not differ across early pregnancy loss and medication abortion groups. Conclusions: Telemedicine follow-up is a feasible alternative to in-person assessment after medication management of early pregnancy loss.
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Affiliation(s)
- Jessica Chen
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sally Nijim
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Anne N Flynn
- The University of California, Davis, Davis, California, USA
| | | | | | - Andrea H Roe
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Raifman S, Gurazada T, Beaman J, Biggs MA, Schwarz EB, Gold M, Grossman D. Primary care and abortion provider perspectives on mail-order medication abortion: a qualitative study. BMC Womens Health 2024; 24:382. [PMID: 38956609 PMCID: PMC11221167 DOI: 10.1186/s12905-024-03202-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 06/11/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND This qualitative study aims to assess perspectives of clinicians and clinic staff on mail-order pharmacy dispensing for medication abortion. METHODS Participants included clinicians and staff involved in implementing a mail-order dispensing model for medication abortion at eleven clinics in seven states as part of a prospective cohort study, which began in January 2020 (before the FDA removed the in-person dispensing requirement for mifepristone). From June 2021 to July 2022, we invited participants at the participating clinics, including six primary care and five abortion clinics, to complete a semi-structured video interview about their experiences. We then conducted qualitative thematic analysis of interview data, summarizing themes related to perceived benefits and concerns about the mail-order model, perceived patient interest, and potential barriers to larger-scale implementation. RESULTS We conducted 24 interviews in total with clinicians (13 physicians and one nurse practitioner) and clinic staff (n = 10). Participants highlighted perceived benefits of the mail-order model, including its potential to expand abortion services into primary care, increase patient autonomy and privacy, and to normalize abortion services. They also highlighted key logistical, clinical, and feasibility concerns about the mail-order model, and specific challenges related to integrating abortion into primary care. CONCLUSION Clinicians and clinic staff working in primary care and abortion clinics were optimistic that mail-order dispensing of medication abortion can improve the ability of some providers to provide abortion and enable more patients to access services. The feasibility of mail-order pharmacy dispensing of medication abortion following the Supreme Court Dobbs decision is to be determined. TRIAL REGISTRATION Registry: Clinicaltrials.gov. TRIAL REGISTRATION NUMBER NCT03913104. Date of registration: first submitted on April 3, 2019 and first posted on April 12, 2019.
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Affiliation(s)
- Sarah Raifman
- Advancing New Standards in Reproductive Health, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA.
| | - Tanvi Gurazada
- Nell Hodgson Woodruff School of Nursing at Emory University, 1520 Clifton Rd, Atlanta, GA, 30322, USA
| | - Jessica Beaman
- San Francisco Division of General Internal Medicine, University of California, 1001 Potrero Ave, San Francisco, CA, USA
| | - M Antonia Biggs
- Advancing New Standards in Reproductive Health, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA
| | - Eleanor Bimla Schwarz
- San Francisco Division of General Internal Medicine, University of California, 1001 Potrero Ave, San Francisco, CA, USA
| | - Marji Gold
- Montefiore Medical Center, Albert Einstein College of Medicine, 3544 Jerome Ave, Bronx, NY, 10467, USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health, University of California, San Francisco, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA
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Ralph LJ, Baba CF, Biggs MA, McNicholas C, Hagstrom Miller A, Grossman D. Comparison of No-Test Telehealth and In-Person Medication Abortion. JAMA 2024:2820321. [PMID: 38913394 PMCID: PMC11197442 DOI: 10.1001/jama.2024.10680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 05/17/2024] [Indexed: 06/25/2024]
Abstract
Importance In the US, access to medication abortion using history-based (no-test) eligibility assessment, including through telehealth and mailing of mifepristone, has grown rapidly. Additional evidence on the effectiveness and safety of these models is needed. Objective To evaluate whether medication abortion with no-test eligibility assessment and mailing of medications is as effective as in-person care with ultrasonography and safe overall. Design, Setting, and Participants Prospective, observational study with noninferiority analysis. Sites included 4 abortion-providing organizations in Colorado, Illinois, Maryland, Minnesota, Virginia, and Washington from May 2021 to March 2023. Eligible patients were seeking medication abortion up to and including 70 days' gestation, spoke English or Spanish, and were aged 15 years or older. Exposure Study groups reflected the model of care selected by the patient and clinicians and included: (1) no-test (telehealth) eligibility assessment and mailing of medications (no-test + mail) (n = 228); (2) no-test eligibility assessment and pickup of medications (no-test + pickup) (n = 119); or (3) in-person with ultrasonography (n = 238). Main Outcomes and Measures Effectiveness, defined as a complete abortion without the need for repeating the mifepristone and misoprostol regimen or a follow-up procedure, and safety, defined as an abortion-related serious adverse event, including overnight hospital admission, surgery, or blood transfusion. Outcomes were derived from patient surveys and medical records. Primary analysis focused on the comparison of the no-test + mail group with the in-person with ultrasonography group. Results The mean age of the participants (N = 585) was 27.3 years; most identified as non-Hispanic White (48.6%) or non-Hispanic Black (28.1%). Median (IQR) gestational duration was 45 days (39-53) and comparable between study groups (P = .30). Outcome data were available for 91.8% of participants. Overall effectiveness was 94.4% (95% CI, 90.7%-99.2%) in the no-test + mail group and 93.3% (95% CI, 88.3%-98.2%) in the in-person with ultrasonography group in adjusted models (adjusted risk difference, 1.2 [95% CI, -4.1 to 6.4]), meeting the prespecified 5% noninferiority margin. Serious adverse events included overnight hospitalization (n = 4), blood transfusion (n = 2), and emergency surgery (n = 1) and were reported by 1.1% (95% CI, 0.4%-2.4%) of participants, with 3 in the no-test + mail group, 3 in the in-person with ultrasonography group, and none in the no-test + pickup group. Conclusions and Relevance This prospective, observational study found that medication abortion obtained following no-test telehealth screening and mailing of medications was associated with similar rates of complete abortion compared with in-person care with ultrasonography and met prespecified criteria for noninferiority, with a low prevalence of adverse events.
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Affiliation(s)
- Lauren J. Ralph
- Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco
| | - C. Finley Baba
- Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco
| | - M. Antonia Biggs
- Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco
| | - Colleen McNicholas
- Planned Parenthood of the St. Louis Region and Southwest Missouri, St Louis
| | - Amy Hagstrom Miller
- Whole Woman’s Health & Whole Woman’s Health Alliance, Charlottesville, Virginia
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), University of California San Francisco
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Horvath S, Wang L, Calo W, Yazer MH. Economic analysis of foregoing Rh immunoglobulin for bleeding in pregnancy <12 weeks gestation. Contraception 2024:110530. [PMID: 38906503 DOI: 10.1016/j.contraception.2024.110530] [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: 11/15/2023] [Revised: 06/11/2024] [Accepted: 06/13/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVES To perform cost analyses of foregoing RhD blood type testing and administration of Rh immunoglobulin (RhIg) for bleeding in pregnancy at <12 weeks gestation in the United States. STUDY DESIGN We created a decision-analytic model comparing the current standard treatment pathway for patients who have threatened, spontaneous, or induced abortion in the United States, with a new pathway foregoing RhD testing and administration of RhIg for those who are RhD-negative at <12 weeks gestation, assuming that the risk of sensitization is 0%. We derived population and cost estimates from the current literature and calculated the number needed to treat (NNT) and number needed to screen to avoid one case of fatal hemolytic disease of the fetus and newborn. We performed sensitivity analyses assuming Rh-sensitization risks of 1.5% and 3% and varying the subsequent pregnancy rates from 44% to 100%. RESULTS The annual savings to health care payers in the United States of foregoing RhD testing and RhIg administration with bleeding events at <12 weeks are $5.5 million/100,000 total pregnancies, assuming the sensitization risk is 0%. In sensitivity analyses with a sensitization risk of 1.5% and subsequent pregnancy rate of 84.3% foregoing Rh testing and RhIg administration would save $2.8 million/100,000 pregnancies, with a NNT of 7322 and a number needed to screen of 48,816. At a 3% sensitization rate, the current standard treatment pathway is most economical. CONCLUSIONS There is an opportunity to save as much as $5.5 million/100,000 pregnancies by withholding RhIg in specific situations and conserving it for use later in pregnancy. IMPLICATIONS Cost analyses support foregoing RhD blood type screening and RhIg administration at <12 weeks gestation if the sensitization rate is <3%. By deimplementing this low-value care, payers in the United States can save as much as $5.5 million/100,000 pregnancies and conserve RhIg for use later in pregnancy.
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Affiliation(s)
- Sarah Horvath
- Department of Obstetrics and Gynecology, H103, Penn State College of Medicine, Hershey Medical Center, Hershey, PA, United States.
| | - Li Wang
- Department of Public Health Sciences, A210, Penn State College of Medicine, Hershey, PA, United States
| | - William Calo
- Department of Public Health Sciences, A210, Penn State College of Medicine, Hershey, PA, United States
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, United States
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Starosta A, Harris J, Gariepy A, Pathy S, Cron J. Medication abortion for adolescents in the United States: Strengthening the role of pediatric primary care providers. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2024; 56:76-84. [PMID: 38661101 DOI: 10.1111/psrh.12264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND Recent legal changes have led to mounting abortion restrictions in the United States (US), disproportionately impacting adolescents, who already face multifaceted barriers to abortion care. Informed by the framework of reproductive justice, adolescents who become pregnant deserve comprehensive, unbiased, and non-judgmental pregnancy options counseling, inclusive of all choices for pregnancy continuation and termination. Pediatric primary care providers are at the front lines of caring for adolescent patients' reproductive health needs and frequently diagnose pregnancy, provide pregnancy options counseling, and assist patients in accessing abortion care. They are uniquely poised to provide this care given their trusted, ongoing relationships with adolescent patients and their families, and their values of deep respect for adolescents' individuality and autonomy. METHODS In this commentary, we aim to describe the medical and legal landscape of adolescent abortion access in the US and provide recommendations to support pediatric primary care providers' involvement in abortion care. We focus on medication abortion, as the provision of medication abortion has the potential to encompass a broad group of clinicians, including pediatric primary care providers. RESULTS We discuss the importance of providing options counseling to adolescents within the reproductive justice framework, improving abortion education for pediatric providers, and expanding access to abortion care by supporting providers at an institutional level if they opt to provide medication abortions. CONCLUSION In light of the current legal landscape, the role of pediatric primary care providers in ensuring adolescent access to abortion care is ever more critical. Although many pediatric and adolescent providers already provide this important care, we, a team of obstetricians/gynecologists and adolescent medicine physicians, echo prior calls for improved training and institutional support for pediatric providers to counsel about and provide abortion-related care. We hope that highlighting the role of pediatric providers in this sphere will help center the needs of adolescent patients and help them fulfill their family planning goals.
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Affiliation(s)
- Anabel Starosta
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Julen Harris
- Department of Pediatrics, Weill Cornell Medical College, New York, New York, USA
| | - Aileen Gariepy
- Department of Obstetrics & Gynecology, Division of Complex Family Planning, Weill Cornell Medical College, New York, New York, USA
| | - Shefali Pathy
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Julia Cron
- Department of Obstetrics & Gynecology, Weill Cornell Medical College, New York, New York, USA
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Moseson H, Jayaweera R, Baum SE, Gerdts C. How Effective Is Misoprostol Alone for Medication Abortion? NEJM EVIDENCE 2024; 3:EVIDccon2300129. [PMID: 38804786 DOI: 10.1056/evidccon2300129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
AbstractWith recent severe restrictions to abortion accessibility in the United States and a pending Supreme Court case challenging the Food and Drug Administration's approval of mifepristone, evidence-based strategies to protect and expand access to abortion care are needed. Two safe and effective regimens for medication abortion are widely used globally - misoprostol-only and misoprostol in combination with mifepristone. However, misoprostol-only regimens are rarely used in the United States. In 2023, the National Abortion Federation and the Society of Family Planning updated their recommended protocol for misoprostol-only for medication abortion to 800 μg of misoprostol administered buccally, sublingually, or vaginally every 3 hours for three or more doses. To characterize the data supporting this specific regimen, this article reviews the relevant literature to address the question of how effective misoprostol-only is for medication abortion. The authors conclude that the updated misoprostol regimen is highly effective and a potential strategy for expanding access to abortion.
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Bar-Noy T, Limonad O, Gandelsman E, Shrim A, Sharabi H, Zarecki R, Hallak M, Bruchim I. The MISOPRED score: Development and validation of a clinical scoring system to predict the effectiveness of Misoprostol treatment for early pregnancy loss. PLoS One 2024; 19:e0303607. [PMID: 38820313 PMCID: PMC11142502 DOI: 10.1371/journal.pone.0303607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 04/28/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND Misoprostol treatment for early pregnancy loss has varied success demonstrated in previous studies. Incorporating predictors in a single clinical scoring system would be highly beneficial in clinical practice. OBJECTIVE To develop and evaluate the accuracy of a scoring system to predict misoprostol treatment outcomes for managing early pregnancy loss. STUDY DESIGN Retrospective cohort and validation study. METHODS Patients discharged from the gynecologic emergency department from 2013 to 2016, diagnosed with early pregnancy loss, who were treated with 800 mcg misoprostol, administrated vaginally were included. All were sonographically reevaluated within 48-72 hours. Patients in whom the gestational sac was not expelled or with endometrial lining >30 mm were offered a repeat dose and returned for reevaluation after seven days. A successful response was defined as complete expulsion. Clinical data were reviewed to identify predictors for successful responses. The scoring system was then retrospectively evaluated on a second cohort to evaluate its accuracy. Multivariate logistic regression was performed to identify factors most predictive of treatment response. RESULTS The development cohort included 126 patients. Six factors were found to be most predictive of misoprostol treatment effectiveness: nulliparity, prior complete spontaneous abortion, gestational age, vaginal bleeding, abdominal pain, and mean sac diameter, yielding a score of 0-8 (the MISOPRED score), where 8 represents the highest-likelihood of success. The score was validated retrospectively with 119 participants. Successful response in the group with the lowest likelihood score (score 0-3) was 9%, compared with 82% in the highest likelihood score group (score 7-8). Using the MISOPRED score, approximately 15% of patients previously planned to receive misoprostol treatment can be referred for surgical management. CONCLUSIONS MISOPRED score can be utilized as an adjunct tool for clinical decision-making in cases of Early pregnancy loss. To our knowledge, this is the first scoring system suggested to predict the success rate in these cases.
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Affiliation(s)
- Tomer Bar-Noy
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
| | - Ofer Limonad
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
| | - Erika Gandelsman
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
| | - Alon Shrim
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
| | - Hila Sharabi
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
| | - Raphy Zarecki
- School of Computer Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Mordechai Hallak
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
| | - Ilan Bruchim
- Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel
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Au HK, Liu CF, Chien LW. Clinical factors associated with subsequent surgical intervention in women undergoing early medical termination of viable or non-viable pregnancies. Front Med (Lausanne) 2024; 11:1188629. [PMID: 38737765 PMCID: PMC11082305 DOI: 10.3389/fmed.2024.1188629] [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: 03/17/2023] [Accepted: 03/29/2024] [Indexed: 05/14/2024] Open
Abstract
Introduction Mifepristone-misoprostol treatment for medical abortion and miscarriage are safe and effective. This study aimed to assess clinical factors associated with subsequent surgical intervention after medical termination of early viable or non-viable pregnancy. Methods This retrospective, single-center study included women who underwent medical abortion at Taipei Medical University between January 2010 and December 2019. A total of 1,561 subjects, with 1,080 viable and 481 non-viable pregnancies, who were treated with oral mifepristone 600 mg followed by misoprostol 600 mg 48 h later were included. Data of all pregnancies and medical termination of pregnancy were evaluated using regression analysis. The main outcome was successful termination of pregnancy. Results The success rate of medical abortion was comparable in women with viable and non-viable (92.13% vs. 92.93%) pregnancies. Besides retained tissue, more existing pregnancies with ultrasonographic findings were found in the non-viable pregnancy group than in the viable pregnancy group (29.4% vs. 14.1%, p = 0.011). Multivariate analysis showed that previous delivery was an independent risk factor for failed medical abortion among all included cases. In women with viable pregnancy, longer gestational age [adjusted odds ratio (aOR): 1.483, 95% confidence interval (CI): 1.224-1.797, p < 0.001] and previous Cesarean delivery (aOR: 2.177, 95% CI: 1.167-40.62, p = 0.014) were independent risk factors for failed medical abortion. Number of Cesarean deliveries (aOR: 1.448, 95% CI: 1.029-2.039, p = 0.034) was an independent risk factor for failed medication abortion in women with non-viable pregnancies. Conclusion This is the first cohort study to identify risk factors for subsequent surgical intervention in women with viable or non-viable pregnancies who had undergone early medically induced abortions. The success rate of medical abortion is comparable in women with viable and non-viable pregnancies. Previous delivery is an independent risk factor for failed medical abortion. Clinical follow-up may be necessary for women who are at risk of subsequent surgical intervention.
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Affiliation(s)
- Heng-Kien Au
- Department of Obstetrics and Gynecology, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan
- Department of Obstetrics and Gynecology, Taipei Medical University Hospital, Taipei City, Taiwan
| | - Chi-Feng Liu
- School of Nursing, National Taipei University of Nursing and Health Science, Taipei City, Taiwan
| | - Li-Wei Chien
- Department of Obstetrics and Gynecology, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan
- Department of Obstetrics and Gynecology, Taipei Medical University Hospital, Taipei City, Taiwan
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14
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Arey W, Lerma K, White K. Self-diagnosing the end of pregnancy after medication abortion. CULTURE, HEALTH & SEXUALITY 2024; 26:405-420. [PMID: 37211833 PMCID: PMC10663384 DOI: 10.1080/13691058.2023.2212298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 05/06/2023] [Indexed: 05/23/2023]
Abstract
This qualitative study conducted between November 2020 and March 2021 in the US state of Mississippi examines the experiences of 25 people who obtained medication abortion at the state's only abortion facility. We conducted in-depth interviews with participants after their abortions until concept saturation was reached, and then analysed the content using inductive and deductive analysis. We assessed how people use embodied knowledge about their individual physical experiences such as pregnancy symptoms, a missed period, bleeding, and visual examinations of pregnancy tissue to identify the beginning and end of pregnancy. We compared this to how people use biomedical knowledge such as pregnancy tests, ultrasounds, and clinical examinations to confirm their self-diagnoses. We found that most people felt confident that they could identify the beginning and end of pregnancy through embodied knowledge, especially when combined with the use of home pregnancy tests that confirmed their symptoms, experiences, and visual evidence. All participants concerned about symptoms sought follow-up care at a medical facility, whereas people who felt confident of the successful end of the pregnancy did so less often. These findings have implications for settings of restricted abortion access that have limited options for follow-up care after medication abortion.
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Affiliation(s)
- Whitney Arey
- Texas Policy Evaluation Project, University of Texas at Austin, Austin, TX, USA
| | - Klaira Lerma
- Texas Policy Evaluation Project, University of Texas at Austin, Austin, TX, USA
| | - Kari White
- Texas Policy Evaluation Project, University of Texas at Austin, Austin, TX, USA
- Department of Sociology, The University of Texas at Austin, Austin, TX, USA
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
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15
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Bharadwa S, Fulcher I, Fortin J, Pocius KD, Goldberg AB. hCG trends after mifepristone and misoprostol for undesired pregnancy of unknown location. Contraception 2024; 131:110343. [PMID: 38008304 DOI: 10.1016/j.contraception.2023.110343] [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: 01/28/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVES To describe human chorionic gonadotropin (hCG) trends for patients with a pregnancy of unknown location (PUL) presenting for medication abortion by management strategy and outcome. STUDY DESIGN This retrospective cohort study included patients presenting for medication abortion with a PUL at ≤42 days gestation managed with either (1) immediate mifepristone with serial hCG follow-up (same-day-start) or (2) hCG testing every 48 to 72 hours ± ultrasonography to confirm pregnancy location followed by treatment (delay-for-diagnosis). The primary outcome was percent hCG change over time between presentation and diagnosis, summarized using a multivariate regression model. RESULTS Of the 55 same-day-start patients, none were treated for ectopic. The eight who eventually required suction curettage had median hCG percent changes (interquartile range) on days 3, 4, and 5 of +57% (-14 to 127; n = 2), +292% (226-353; n = 4), and +392% (n = 1), while the 41 successful medication abortions had declines of -64% (n = 1), -65% (-75 to -27; n = 17), and -77% (-85 to -68; n = 13). Of the 380 delay-for-diagnosis patients, the 30 ectopic pregnancies had day 3, 4, and 5 changes of +38% (-17 to 56; n = 14), +50% (17-71; n = 7), and +115% (87-177; n = 4). None of the ectopic pregnancies declined ≥50% by days 3 to 5. The hCG trend for ectopic pregnancies differed from successful medication abortions (p < 0.01), but not medication abortions with retained intrauterine pregnancies (p = 0.41). CONCLUSIONS Serum hCG trends can help differentiate ectopic pregnancy from successful medication abortion, but cannot distinguish between ectopic and retained intrauterine pregnancy. IMPLICATIONS Serial serum hCG testing is effective for confirming successful medication abortion and identifying patients requiring further follow-up among patients undergoing medication abortion for an undesired PUL.
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Affiliation(s)
- Sonya Bharadwa
- Harvard Medical School, Boston, MA, United States; Brigham & Women's Hospital, Department of Obstetrics, Gynecology, and Reproductive Biology, Boston, MA, United States.
| | - Isabel Fulcher
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, United States; The Planned Parenthood League of Massachusetts, Boston, MA, United States
| | - Jennifer Fortin
- The Planned Parenthood League of Massachusetts, Boston, MA, United States
| | - Katherine D Pocius
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, United States; Massachusetts General Hospital, Boston, MA, United States
| | - Alisa B Goldberg
- Harvard Medical School, Boston, MA, United States; Brigham & Women's Hospital, Department of Obstetrics, Gynecology, and Reproductive Biology, Boston, MA, United States; The Planned Parenthood League of Massachusetts, Boston, MA, United States
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16
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Preiksaitis C, Saxena M, Henkel A. Initiating medical abortion in an emergency department in the United States. BMJ SEXUAL & REPRODUCTIVE HEALTH 2024:bmjsrh-2023-202149. [PMID: 38365454 DOI: 10.1136/bmjsrh-2023-202149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/05/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVES The primary objective of this study was to assess the feasibility of initiating medical abortions in a large, academic emergency department (ED) in the United States. METHODS A retrospective case series analysis was conducted to evaluate a protocol for initiating medical abortion in the ED implemented from January 2020 to October 2023 at an academic, tertiary care hospital in California, USA. Participants included ED patients diagnosed with pregnancies in the first trimester that were undesired and who opted for medical abortion. The medical abortion protocol was collaboratively designed by a multidisciplinary team and follow-up was conducted by our institution's gynaecology department. Data were sourced from a data repository of electronic health records and subjected to descriptive statistical analysis. RESULTS A total of 27 eligible patients initiated medical abortions in the ED during the study period. The cohort was diverse in terms of racial and ethnic backgrounds and almost evenly split between private and public insurance. No patients had significant complications identified in the medical record. Two patients required uterine aspiration by the gynaecology team; one patient in clinic and one during a return visit to the ED. CONCLUSIONS Data from this case series suggest that initiating medical abortion in the ED is feasible. The ED may be considered as an additional access point for abortion care services, especially in areas where other care options are not readily available. Educational, legal and regulatory frameworks that allow emergency physicians to take a greater role in providing this care should be considered.
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Affiliation(s)
- Carl Preiksaitis
- Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Monica Saxena
- Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Andrea Henkel
- Obstetrics & Gynecology, Stanford University School of Medicine, Palo Alto, California, USA
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Koenig LR, Ko J, Valladares ES, Coeytaux FM, Wells E, Lyles CR, Upadhyay UD. Patient Acceptability of Telehealth Medication Abortion Care in the United States, 2021‒2022: A Cohort Study. Am J Public Health 2024; 114:241-250. [PMID: 38237103 PMCID: PMC10862199 DOI: 10.2105/ajph.2023.307437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
Objectives. Despite the recent expansion of direct-to-patient telehealth abortion care in the United States, patient experiences with the service are not well understood. Methods. We described care experiences of 1600 telehealth abortion patients in 2021 to 2022 and used logistic regression to explore differences by race or ethnicity and between synchronous (phone or video) and asynchronous (secure messaging) telehealth abortion care. Results. Most patients trusted the provider (98%), felt telehealth was the right decision (96%), felt cared for (92%), and were very satisfied (89%). Patients most commonly cited privacy (76%), timeliness (74%), and staying at home (71%) as benefits. The most commonly reported drawback was initial uncertainty about whether the service was legitimate (38%). Asian patients were less likely to be very satisfied than White patients (79% vs 90%; P = .008). Acceptability was high for both synchronous and asynchronous care. Conclusions. Telehealth abortion care is highly acceptable, and benefits include privacy and expediency. Public Health Implications. Telehealth abortion can expand abortion access in an increasingly restricted landscape while maintaining patient-centered care. (Am J Public Health. 2024;114(2):241-250. https://doi.org/10.2105/AJPH.2023.307437).
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Affiliation(s)
- Leah R Koenig
- Leah R. Koenig, Jennifer Ko, and Ushma D. Upadhyay are with Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland. Ena Suseth Valladares is with California Latinas for Reproductive Justice, Los Angeles. Francine M. Coeytaux and Elisa Wells are with Plan C. Courtney R. Lyles is with the Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Jennifer Ko
- Leah R. Koenig, Jennifer Ko, and Ushma D. Upadhyay are with Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland. Ena Suseth Valladares is with California Latinas for Reproductive Justice, Los Angeles. Francine M. Coeytaux and Elisa Wells are with Plan C. Courtney R. Lyles is with the Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Ena Suseth Valladares
- Leah R. Koenig, Jennifer Ko, and Ushma D. Upadhyay are with Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland. Ena Suseth Valladares is with California Latinas for Reproductive Justice, Los Angeles. Francine M. Coeytaux and Elisa Wells are with Plan C. Courtney R. Lyles is with the Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Francine M Coeytaux
- Leah R. Koenig, Jennifer Ko, and Ushma D. Upadhyay are with Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland. Ena Suseth Valladares is with California Latinas for Reproductive Justice, Los Angeles. Francine M. Coeytaux and Elisa Wells are with Plan C. Courtney R. Lyles is with the Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Elisa Wells
- Leah R. Koenig, Jennifer Ko, and Ushma D. Upadhyay are with Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland. Ena Suseth Valladares is with California Latinas for Reproductive Justice, Los Angeles. Francine M. Coeytaux and Elisa Wells are with Plan C. Courtney R. Lyles is with the Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Courtney R Lyles
- Leah R. Koenig, Jennifer Ko, and Ushma D. Upadhyay are with Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland. Ena Suseth Valladares is with California Latinas for Reproductive Justice, Los Angeles. Francine M. Coeytaux and Elisa Wells are with Plan C. Courtney R. Lyles is with the Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Ushma D Upadhyay
- Leah R. Koenig, Jennifer Ko, and Ushma D. Upadhyay are with Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland. Ena Suseth Valladares is with California Latinas for Reproductive Justice, Los Angeles. Francine M. Coeytaux and Elisa Wells are with Plan C. Courtney R. Lyles is with the Department of Epidemiology and Biostatistics, University of California, San Francisco
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18
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Peart MS, Cartwright AF, Tadikonda A, Upadhyay UD, Tang JH, Morse JE, Stuart GS, Bryant AG. Potential demand for and access to medication abortion among North Carolina college students. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2024:1-8. [PMID: 38227925 DOI: 10.1080/07448481.2023.2299408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 11/20/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE To estimate demand for medication abortion (MAB) among North Carolina (NC) college students and describe access to nearest clinics offering MAB to each campus. METHODS We calculated demand using 2019-2020 campus demographics and NC abortion statistics. We used a mystery client technique to gather MAB cost and appointment wait times at the closest clinics and calculated travel distances and times. RESULTS We estimated that 2,517 NC students seek MAB annually. Twenty-one clinics were closest to NC's 111 colleges and universities, including five in neighboring states. Mean cost was $450, with an average wait time of six days to appointment. The average round-trip travel distance was 58 miles and time to the nearest clinic was 84 min by car. CONCLUSIONS Many NC college students likely obtain MAB every year and face high costs, long wait times and distances to care, which has likely worsened after the overturning of Roe v. Wade.
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Affiliation(s)
- Mishka S Peart
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Alice F Cartwright
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ananya Tadikonda
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ushma D Upadhyay
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, California, USA
| | - Jennifer H Tang
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Jessica E Morse
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Gretchen S Stuart
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Amy G Bryant
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Stifani BM, Lavelanet AF. Reversal of medication abortion with progesterone: a systematic review. BMJ SEXUAL & REPRODUCTIVE HEALTH 2024; 50:43-52. [PMID: 37863512 PMCID: PMC10850668 DOI: 10.1136/bmjsrh-2023-201875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 09/15/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND We sought to determine whether there is evidence to recommend progesterone for individuals not wishing to complete a medication abortion after taking mifepristone. METHODS We undertook an updated systematic review including a primary search for studies in which individuals received progesterone to reverse the effects of mifepristone, and a secondary search for studies in which individuals received mifepristone alone. We searched PubMed, Embase, Cochrane, CINAHL and grey literature up to December 2022. We used the Joanna Briggs Institute critical appraisal tools for risk of bias assessment. We compared ongoing pregnancy rates among individuals treated with progesterone to those managed expectantly. RESULTS We did not find new studies in our secondary search. For the main search, we included three case series and one randomised controlled trial. Data were available for 561 individuals who received progesterone after mifepristone, of whom 271 (48%) had ongoing pregnancies. The quality of the evidence in the case series was low due to methodological and ethical issues. Enrollment in the randomised trial stopped early due to bleeding events in both arms. The ongoing pregnancy rate for individuals ≤7 weeks who received progesterone was 42% (95% CI 37-48) compared with 22% (95% CI 11-39) for mifepristone alone. At 7-8 weeks, the ongoing pregnancy rate was 62% (95% CI 52-71) in the progesterone group and 50% (95% CI 15- 85) in the mifepristone alone group. CONCLUSION Based mostly on poor-quality data, it appears the ongoing pregnancy rate in individuals treated with progesterone after mifepristone is not significantly higher compared to that of individuals receiving mifepristone alone.
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Affiliation(s)
- Bianca Maria Stifani
- Department of Obstetrics & Gynecology, Westchester Medical Center / New York Medical College, Valhalla, New York, USA
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Kelesidou V, Tsakiridis I, Virgiliou A, Dagklis T, Mamopoulos A, Athanasiadis A, Kalogiannidis I. Combination of Mifepristone and Misoprostol for First-Trimester Medical Abortion: A Comprehensive Review of the Literature. Obstet Gynecol Surv 2024; 79:54-63. [PMID: 38306292 DOI: 10.1097/ogx.0000000000001222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
Importance Several medications have been used to achieve medical abortion in the first trimester of pregnancy. The most commonly used is the combination of mifepristone and misoprostol; however, different doses and routes of administration have been proposed. Objective The aim of this study was to summarize published data on the effectiveness, adverse effects, and acceptability of the various combinations of mifepristone and misoprostol in medical abortion protocols in the first trimester of pregnancy. Evidence Acquisition This was a comprehensive review, synthesizing the findings of the literature on the current use of mifepristone and misoprostol for first-trimester abortion. Results The combination of mifepristone and misoprostol seems to be more effective than misoprostol alone. Regarding the dosages and routes, mifepristone is administered orally, and the optimal dose is 200 mg. The route of administration of misoprostol varies; the sublingual and buccal routes are more effective; however, the vaginal route (800 μg) is associated with fewer adverse effects. Finally, the acceptability rates did not differ significantly. Conclusions Different schemes for first-trimester medical abortion have been described so far. Future research needs to focus on identifying the method that offers the best trade-off between efficacy and safety in first-trimester medical abortion.
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Affiliation(s)
- Vera Kelesidou
- Resident, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Ioannis Tsakiridis
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Andriana Virgiliou
- Consultant in Obstetrics and Gynecology, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Themistoklis Dagklis
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Apostolos Mamopoulos
- Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Apostolos Athanasiadis
- Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Ioannis Kalogiannidis
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
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Fraz F, Liu SM, Shaw KA. Cervical preparation for second-trimester procedural abortion. Curr Opin Obstet Gynecol 2023; 35:470-475. [PMID: 37678155 DOI: 10.1097/gco.0000000000000912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
PURPOSE OF REVIEW To review the evidence-informed options for cervical preparation prior to second-trimester dilation and evacuation (D&E). RECENT FINDINGS As abortion restrictions increase and the number of abortion clinics and providers decreases, pregnant people are facing more barriers to abortion access. Those in need are now often required to travel for second-trimester abortion care, only to be faced with additional restrictions, such as mandatory waiting periods. Cervical preparation is recommended prior to D&E and takes time for effect. Given the increasing time required to obtain an abortion, patients and providers may prefer same-day cervical preparation to decrease the total time required. Options for same-day cervical preparation include misoprostol alone with single or serial doses, and misoprostol combined with osmotic dilators or transcervical balloon (Foley catheter). Same-day preparation may require additional clinical space to accommodate people after initiation of cervical preparation to manage side-effects and timing of the abortion. Overnight options are also used and more frequently later in the second trimester. Overnight options include mifepristone, osmotic dilators, and transcervical balloon and are often combined with same-day misoprostol. Medication alone preparation is well tolerated and effective in the second trimester, with the addition of mechanical methods with advancing gestation. With many options and combinations being safe and effective, providers can be dynamic and alter approach with supply shortages, adjust to different clinical settings, consider patient medical and surgical factors, and accommodate provider and patient preferences. SUMMARY Multiple pharmacologic and mechanical options have been shown to be safe and effective for cervical preparation prior to D&E. Consideration for multiple factors should influence the method of cervical preparation and methods may vary by patient, provider and setting.
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Affiliation(s)
- Farsam Fraz
- Division of Gynecology and Gynecologic Specialities, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
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22
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Dunlop H, Sinay AM, Kerestes C. Telemedicine Abortion. Clin Obstet Gynecol 2023; 66:725-738. [PMID: 37910115 DOI: 10.1097/grf.0000000000000818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Telemedicine has become a substantial part of abortion care in recent years. In this review, we discuss the history and regulatory landscape of telemedicine for medication abortion in the United States, different models of care for telemedicine, and the safety and effectiveness of medication abortion via telemedicine, including using history-based screening protocols for medication abortion without ultrasound. We also explore the acceptability of telemedicine for patients and their perspectives on its benefits, as well as the use of telemedicine for other parts of abortion care. Telemedicine has expanded access to abortion for many, although there remain limitations to its implementation.
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Affiliation(s)
| | - Anne-Marie Sinay
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
| | - Courtney Kerestes
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio
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23
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Fleurant E, McCloskey L. Medication Abortion: A Comprehensive Review. Clin Obstet Gynecol 2023; 66:706-724. [PMID: 37910067 DOI: 10.1097/grf.0000000000000812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
This chapter provides an overview of evidence-based guidelines for medication abortion in the first trimester. We discuss regimens, both FDA-approved and other clinical-based protocols, and will briefly discuss novel self-managed abortion techniques taking place outside the formal health care system. Overview of patient counseling and pain management are presented with care to include guidance on "no touch" regimens that have proven both feasible and effective. We hope that this comprehensive review helps the health care community make strides to increase access to abortion in a time when reproductive health care is continuously restricted.
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Affiliation(s)
- Erin Fleurant
- Department of Obstetrics and Gynecology, Northwestern McGaw Medical Center, Chicago, Illinois
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24
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McLaren H, Hennessey C. First-trimester Procedural Abortion. Clin Obstet Gynecol 2023; 66:676-684. [PMID: 37750678 DOI: 10.1097/grf.0000000000000808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
First-trimester abortion is a common and safe procedure. A focused history and physical examination are essential for providing this care. Laboratory assessment can include Rh typing, hemoglobin, and cervicitis testing as indicated by a patient's risk factors. Procedural abortion in the first trimester includes cervical dilation with or without cervical preparation, and uterine evacuation utilizing a manual vacuum aspirator or electric vacuum aspirator. Complications occur rarely and are often easily managed at the time of diagnosis.
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Affiliation(s)
- Hillary McLaren
- Department of Obstetrics and Gynecology, Section of Complex Family Planning, University of Chicago, Chicago, Illinois
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25
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Jung C, Nippita S. Self-managed Medication Abortion in the United States. Clin Obstet Gynecol 2023; 66:739-748. [PMID: 37750672 DOI: 10.1097/grf.0000000000000810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Self-managed abortion (SMA) is ending a pregnancy without medical supervision, either by obtaining medications (known as self-managed medication abortion) or through other means. Many factors influence a person's decision to pursue self-managed abortion, such as time constraints, financial considerations, and local availability of abortion services. We present on the prevalence, methods and best practices for clinicians in the United States who may interface with individuals undergoing self-managed medication abortion at any point in the process through a harm reduction approach.
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Affiliation(s)
- Christina Jung
- Department of Obstetrics and Gynecology, NYU Grossman School of Medicine, New York, New York
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Silva TMD, Araujo MAGD, Simões ACZ, Oliveira RD, Medeiros KSD, Sarmento AC, Medeiros RDD, Costa APF, Gonçalves AK. Efficacy, Safety, and Acceptability of Misoprostol in the Treatment of Incomplete Miscarriage: A Systematic Review and Meta-analysis. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:e808-e817. [PMID: 38141602 DOI: 10.1055/s-0043-1776029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2023] Open
Abstract
OBJECTIVE To assess the efficacy, safety, and acceptability of misoprostol in the treatment of incomplete miscarriage. DATA SOURCES The PubMed, Scopus, Embase, Web of Science, Cochrane Library, and Clinical Trials databases (clinicaltrials.gov) were searched for the relevant articles, and search strategies were developed using a combination of thematic Medical Subject Headings terms and text words. The last search was conducted on July 4, 2022. No language restrictions were applied. SELECTION OF STUDIES Randomized clinical trials with patients of gestational age up to 6/7 weeks with a diagnosis of incomplete abortion and who were managed with at least 1 of the 3 types of treatment studied were included. A total of 8,087 studies were screened. DATA COLLECTION Data were synthesized using the statistical package Review Manager V.5.1 (The Cochrane Collaboration, Oxford, United Kingdom). For dichotomous outcomes, the odds ratio (OR) and 95% confidence interval (CI) were derived for each study. Heterogeneity between the trial results was evaluated using the standard test, I2 statistic. DATA SYNTHESIS When comparing misoprostol with medical vacuum aspiration (MVA), the rate of complete abortion was higher in the MVA group (OR = 0.16; 95%CI = 0.07-0.36). Hemorrhage or heavy bleeding was more common in the misoprostol group (OR = 3.00; 95%CI = 1.96-4.59), but pain after treatment was more common in patients treated with MVA (OR = 0.65; 95%CI = 0.52-0.80). No statistically significant differences were observed in the general acceptability of the treatments. CONCLUSION Misoprostol has been determined as a safe option with good acceptance by patients.
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Affiliation(s)
- Thiago Menezes da Silva
- Maternidade Escola Januário Cicco, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | | | | | - Ronnier de Oliveira
- Maternidade Escola Januário Cicco, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | - Kleyton Santos de Medeiros
- Centro de Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
- Instituto de Ensino, Pesquisa e Inovação, Liga Contra o Câncer, Natal, RN, Brazil
| | | | - Robinson Dias de Medeiros
- Department of Obstetrics and Gynecology, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | | | - Ana Katherine Gonçalves
- Centro de Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
- Department of Obstetrics and Gynecology, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
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Jayaweera R, Egwuatu I, Nmezi S, Kristianingrum IA, Zurbriggen R, Grosso B, Bercu C, Gerdts C, Moseson H. Medication Abortion Safety and Effectiveness With Misoprostol Alone. JAMA Netw Open 2023; 6:e2340042. [PMID: 37889485 PMCID: PMC10611991 DOI: 10.1001/jamanetworkopen.2023.40042] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/12/2023] [Indexed: 10/28/2023] Open
Abstract
Importance Misoprostol-alone regimens for abortion may be more effective than previously thought. Objective To estimate the effectiveness of medication abortion with misoprostol alone among individuals self-managing their abortion. Design, Setting, and Participants For this prospective observational cohort study of callers to safe abortion hotlines and accompaniment groups in Argentina, Nigeria, and Southeast Asia, participants were recruited between July 31, 2019, and October 1, 2020, prior to starting their medication abortion. Eligible participants were 13 years or older, had no contraindications to medication abortion, and were not currently bleeding. Participants completed a baseline and 2 follow-up surveys. The analysis was restricted to participants who reported using misoprostol alone and was performed between January 6, 2022 and September 8, 2023. Exposure Self-managed medication abortion using misoprostol alone. Main Outcomes and Measures The primary outcome was effectiveness, defined as participant self-report of complete abortion without procedural intervention, measured at 1 week and 3 weeks after taking misoprostol. Secondary outcomes included method safety, measured by self-report of experiencing warning signs (eg, heavy bleeding, pain, fever, discharge) indicative of a potential complication and by medical treatment (eg, blood transfusion, intravenous fluids, overnight hospital stay) indicative of a potential adverse event. Additional outcomes included length of bleeding and cramping, time to expulsion, and experience of adverse effects. Results Among 1352 enrolled participants, 637 used misoprostol-alone regimens for abortion and were included in the analysis (591 [92.8%] from Nigeria, 45 [7.1%] from Southeast Asia, and 1 [0.2%] from Argentina; 384 [60.2%] aged 20-29 years; 317 [49.8%] with pregnancy durations <7 weeks and 205 [32.2%] with pregnancy durations between 7 and <9 weeks). At last follow-up after taking medication (median, 22 days; IQR, 21-26 days), 625 participants (98.1%; 95% CI, 96.7%-98.9%) had a complete abortion without procedural intervention. Potential adverse events were reported by 6 participants (0.9%; 95% CI, 0.4%-2.1%). Most participants experienced bleeding for less than 1 week (median, 4 days; IQR, 3-6 days) and expelled their pregnancy within 24 hours of starting the abortion process (median, 12 hours; IQR, 9-15 hours). Common side effects included nausea (335 participants [52.6%]), fever (232 [36.4%]), and diarrhea (181 [28.4%]). Conclusions and Relevance The findings suggest that misoprostol alone is a highly effective method of pregnancy termination. Future research should explore strategies to maximize the effectiveness of misoprostol alone in clinical and nonclinical settings.
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Affiliation(s)
| | - Ijeoma Egwuatu
- Generation Initiative Women and Youth Network, Lagos, Nigeria
| | - Sybil Nmezi
- Generation Initiative Women and Youth Network, Lagos, Nigeria
| | | | | | - Belén Grosso
- La Revuelta Colectiva Feminista, Neuquén, Argentina
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28
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Banwarth-Kuhn B, McQuade M, Krashin JW. Vaginal Bleeding Before 20 Weeks Gestation. Obstet Gynecol Clin North Am 2023; 50:473-492. [PMID: 37500211 DOI: 10.1016/j.ogc.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Conditions that often present with vaginal bleeding before 20 weeks are common and can cause morbidity and mortality. Clinically stable patients can choose their management options. Clinically unstable patients require urgent procedural management: uterine aspiration, dilation and evacuation, or surgical removal of an ectopic pregnancy. Septic abortion requires prompt procedural management, intravenous antibiotics, and intravenous fluids. Available data on prognosis with expectant management of pre-viable rupture of membranes in the United States are poor for mothers and fetuses.
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Affiliation(s)
| | | | - Jamie W Krashin
- Department of Obstetrics & Gynecology, University of New Mexico Health Sciences Center, MSC 10 5580, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA.
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29
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Ehrenreich K, Baba CF, Raifman S, Grossman D. Perspectives on Alternative Models of Medication Abortion Provision Among Abortion Patients in the United States. Womens Health Issues 2023; 33:481-488. [PMID: 37105836 DOI: 10.1016/j.whi.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 03/13/2023] [Accepted: 03/24/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE Restrictions on the availability of medication abortion are a barrier to accessing early abortion. People seeking medication abortion may be interested in obtaining the medications through alternative models. The purpose of this study was to explore patient perspectives on obtaining abortion medications in advance of pregnancy or over the counter (OTC). STUDY DESIGN Between October 2017 and August 2018, we conducted 30 in-depth interviews with abortion patients who indicated support for alternative models. We recruited patients from 10 abortion clinics in states with a range of policy environments. We analyzed interviews using inductive and deductive iterative techniques. RESULTS Participants identified logistical benefits of these alternative models, including eliminating travel to a clinic and multiple appointments, and increased privacy around decision-making. Participants were interested in advance provision for its convenience and the sense of preparedness that would come with having the pills available at home, yet some had concerns about the pills being found or stolen. Privacy was the key factor considered for OTC access, including both the privacy benefits of avoiding a clinic and the concern of having one's privacy compromised within the community if purchasing the medications in public. CONCLUSIONS People who have previously had a medication abortion are interested in alternative methods of provision for reasons concerning convenience, privacy, and avoiding burdens related to hostile policy environments, such as long travel distances to clinics and multiple appointments. Concerns around these models were primarily safety concerns for young people. Further research is needed to evaluate the safety, effectiveness, acceptability, and feasibility of these alternative models of providing medication abortion.
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Affiliation(s)
- Katherine Ehrenreich
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, California.
| | - C Finley Baba
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Sarah Raifman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, California
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30
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Abu Esba LC, Al Mardawi G, Al Mardawi E, Almadhi FM, Ardah HI. Misoprostol-Induced Fever and Unnecessary Antibiotic Prescribing: A Retrospective Study. Infect Dis Ther 2023; 12:2259-2268. [PMID: 37704800 PMCID: PMC10581965 DOI: 10.1007/s40121-023-00865-3] [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: 06/13/2023] [Accepted: 08/24/2023] [Indexed: 09/15/2023] Open
Abstract
INTRODUCTION Misoprostol is widely used for medication abortion and postpartum hemorrhage. However, it has been associated with the adverse effect of fever, which can pose challenges in management and potentially contribute to unnecessary antibiotic use. The incidence of misoprostol-induced fever in the context of medical abortion has not been extensively studied. METHODS This retrospective cohort study aimed to determine the incidence of fever following misoprostol administration at a tertiary care hospital in Saudi Arabia. The study included female patients who received misoprostol for pregnancy termination or management of missed or incomplete abortion between January 2017 and December 2019. Data on demographics, misoprostol dosage and route, fever characteristics, outcome of abortion, and antibiotic use were collected. Statistical analysis was preformed using appropriate tests. RESULTS A total of 213 patients were included in the study. The incidence of fever post-misoprostol administration was 8%. Patients who developed fever had a higher gestational age and received higher doses of misoprostol. However, no significant associations were found between other patient variables and fever incidence. Antibiotic therapy was administered to a almost half of the patients who developed fever post-misoprostol but was determined to be unnecessary in all cases. CONCLUSION This study contributes to the understanding of misoprostol-induced fever in the context of medical abortion. Further research is needed to explore strategies for reducing unnecessary antibiotic use in this population.
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Affiliation(s)
- Laila Carolina Abu Esba
- King Abdulaziz Medical City, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - Ghada Al Mardawi
- King Abdulaziz Medical City, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - Elham Al Mardawi
- Department of Obstetric and Gynecology, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Fay Musaed Almadhi
- King Abdulaziz Medical City, Ministry of National Guard, Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - Husam I. Ardah
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Biostatistics and Bioinformatics, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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31
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Wong ML, Achu RA, Spence NZ, White KO. Feasibility of methadone for pain relief in first trimester abortion (Boston, Massachusetts 2022). Contraception 2023; 125:110052. [PMID: 37105280 DOI: 10.1016/j.contraception.2023.110052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/15/2023] [Accepted: 03/15/2023] [Indexed: 04/29/2023]
Affiliation(s)
- Melissa L Wong
- Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
| | - Rachel A Achu
- Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
| | - Nicole Z Spence
- Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
| | - Katharine O White
- Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
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32
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Cirucci CA. Self-Managed Medication Abortion: Implications for Clinical Practice. LINACRE QUARTERLY 2023; 90:273-289. [PMID: 37841380 PMCID: PMC10566489 DOI: 10.1177/00243639221128389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Medication abortion represents more than 50 percent of abortions in the United States (US). Since its approval in the US in 2000, the Food and Drug Administration (FDA) has progressively relaxed the prescribing requirements such that currently, no office visit, in-person dispensing, or ultrasound is required. Obtaining medication for abortion online without medical supervision or evaluation is also possible. This article reviews the complications of medication abortion by examining major studies and delineates the risks specific to self-managed abortion to inform clinicians in caring for women. Summary Medication abortion has become the most common abortion method in the United States. This document provides a detailed history of the relaxation requirements on medication abortion and reviews the major studies on medication abortion complications including a discussion of their limitations. Finally, the paper delineates the ease of access to medication abortion without a health care provider and the risks associated with self-managed abortion. This paper is intended to provide information for clinicians who likely will be encountering increasing number of patients with such complications.
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Anger HA, Raymond EG. Implications of using home urine pregnancy tests versus facility-based tests for assessment of outcome following medication abortion provided via telemedicine. Contraception 2023; 124:110055. [PMID: 37088124 DOI: 10.1016/j.contraception.2023.110055] [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: 12/11/2022] [Revised: 04/15/2023] [Accepted: 04/19/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVES To assess whether planning high-sensitivity urine pregnancy tests (HSPT) rather than facility-based tests for medication abortion follow-up may increase risk of unplanned clinical visits or procedural completion of the abortion. STUDY DESIGN We used data from the TelAbortion Project, a 5-year study assessing the safety and feasibility of providing mifepristone and misoprostol by telemedicine and mail in the United States. We categorized participants by whether the pretreatment follow-up plan included HSPT at home 3-5 weeks after treatment or facility-based tests (ultrasound or serum human chorionic gonadotropin) within 2 weeks after treatment. We used multivariable logistic regression to compare likelihood of post-treatment unplanned, abortion-related clinical visits and procedural intervention in these groups. RESULTS Of 1324 patients who planned HSPT follow-up and 576 who planned facility-based tests, 85% and 83%, respectively, provided outcome information. Post-treatment clinical visits were less frequent in the HSPT group (19%) than in the facility-based test group (79%); most of the latter were to obtain the planned test. However, unplanned, abortion-related visits were significantly more common in the HSPT group (adjusted risk difference: 6.5%; p < 0.01). The likelihood of procedural completion did not differ by group. Planned follow-up test was not associated with delay in procedural completion or detection of ongoing pregnancy. CONCLUSIONS Follow-up of medication abortion with home HSPT was associated with fewer post-treatment clinical visits, modestly more unplanned, abortion-related clinical visits, and no increase in the risk of procedural interventions or delayed identification or management of treatment failures. This option is an appropriate follow-up approach after medication abortion. IMPLICATIONS Use of home high-sensitivity pregnancy tests rather than facility-based tests for outcome assessment after medication abortion is associated with a modest increase in unplanned clinical visits but does not lead to an increase in procedural interventions or delays identification and management of treatment failure.
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Affiliation(s)
- Holly A Anger
- Gynuity Health Projects, New York, NY, USA; Department of Epidemiology and Biostatistics, City University of New York Graduate School of Public Health and Health Policy, New York, NY, USA
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34
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French V. Where Do We Stand With Mifepristone in the United States?: Making Sense of the Madness. Obstet Gynecol 2023; 142:234-235. [PMID: 37225395 DOI: 10.1097/aog.0000000000005253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/26/2023]
Affiliation(s)
- Valerie French
- Valerie French is from the University of Kansas Department of Obstetrics and Gynecology, Kansas City, Kansas;
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35
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Joslyn PW, Barkemeyer AK, Gupta RW, Barkemeyer BM. Fetal methotrexate syndrome following an unsuccessful medication abortion - a rare syndrome posed to become more common. Clin Dysmorphol 2023; 32:129-132. [PMID: 37195300 DOI: 10.1097/mcd.0000000000000459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Affiliation(s)
| | - Amanda K Barkemeyer
- Department of Pediatrics, Louisiana State University Health Sciences Center New Orleans, Louisiana, USA
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36
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Hau NV, Han LTK, Minh LHN, Kiet NA, Phong T, Duong NK, Yen PTH, Vinh NX, Hao NQN, Nguyen N, Truyen TTTT, Le NK. A case report and literature review of myocardial infarction with nonobstructive coronary arteries (MINOCA) possibly due to acute coronary vasospasm induced by misoprostol. Front Cardiovasc Med 2023; 10:1115358. [PMID: 37304962 PMCID: PMC10250731 DOI: 10.3389/fcvm.2023.1115358] [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] [Received: 12/03/2022] [Accepted: 04/21/2023] [Indexed: 06/13/2023] Open
Abstract
Coronary artery vasospasm (CVS), an uncommon cause of acute chest pain, can be provoked by vasoconstriction-induced medications. Misoprostol, a prostaglandin analog, is a safe medication to terminate a pregnancy. However, misoprostol can cause coronary artery vasospasm due to vasoconstrictor properties, leading to acute myocardial infarction with nonobstructive coronary arteries (MINOCA), especially in patients with a high risk for cardiovascular disease. We report a case of a 42-year-old female with a past medical history of hypertension who presented with ST-elevation myocardial infarction following the administration of a high-dose Misoprostol. The fact that coronary angiogram and intravascular ultrasound revealed normal coronary arteries suggested transient coronary vasospasm. CVS is a severe but rare cardiac adverse effect associated with high-dose misoprostol. This medication should be prescribed with caution and close monitoring, especially in those with pre-existing heart disease or cardiovascular risk factors. Our case raises awareness of severe cardiovascular complications that can be related to using misoprostol in high-risk patients.
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Affiliation(s)
- Nguyen Viet Hau
- Emergency Department, University Medical Center, Ho Chi Minh City, Vietnam
| | - Luu Thi Kim Han
- Emergency Department, University Medical Center, Ho Chi Minh City, Vietnam
| | - Le Huu Nhat Minh
- Emergency Department, University Medical Center, Ho Chi Minh City, Vietnam
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- AIBioMed Research Group, Taipei Medical University, Taipei, Taiwan
- Research Center for Artificial Intelligence in Medicine, Taipei Medical University, Taipei, Taiwan
| | - Nguyen Anh Kiet
- Emergency Department, University Medical Center, Ho Chi Minh City, Vietnam
| | - Tang Tuan Phong
- Emergency Department, University Medical Center, Ho Chi Minh City, Vietnam
| | - Nguyen Khanh Duong
- Emergency Department, University Medical Center, Ho Chi Minh City, Vietnam
| | - Phan Thi Hoang Yen
- Emergency Department, University Medical Center, Ho Chi Minh City, Vietnam
| | - Nguyen Xuan Vinh
- Emergency Department, University Medical Center, Ho Chi Minh City, Vietnam
| | | | - Nguyen Nguyen
- Department of Internal Medicine, Palmetto General Hospital, Hialeah, FL, United States
| | | | - Nguyen Quoc Khanh Le
- AIBioMed Research Group, Taipei Medical University, Taipei, Taiwan
- Research Center for Artificial Intelligence in Medicine, Taipei Medical University, Taipei, Taiwan
- Professional Master Program in Artificial Intelligence in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Translational Imaging Research Center, Taipei Medical University Hospital, Taipei, Taiwan
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Manning S, Kuhn D. Spontaneous and Complicated Therapeutic Abortion in the Emergency Department. Emerg Med Clin North Am 2023; 41:295-305. [PMID: 37024165 DOI: 10.1016/j.emc.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Pregnancy-related emergency department visits are common in the United States. Although typically managed safely in the outpatient setting, patients with spontaneous abortion may also present with life-threatening hemorrhage or infection. Management strategies for spontaneous abortion are similarly wide-ranging from expectant management to emergent surgical intervention. Surgical management of complicated therapeutic abortion is similar to that of spontaneous abortion. The dramatic changes in the legal status of abortion in the United States may have significant influence on the incidence of complicated therapeutic abortion, and we encourage emergency physicians to familiarize themselves with the diagnosis and management of these conditions.
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Eckstein SM, von Felten S, Perotto L, Brun R, Vorburger D. First trimester abortion protocols by facility type in Switzerland and potential barriers to accessing the service. Sci Rep 2023; 13:6814. [PMID: 37100827 PMCID: PMC10131519 DOI: 10.1038/s41598-023-34101-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 04/24/2023] [Indexed: 04/28/2023] Open
Abstract
Simplified first-trimester abortion protocols are well established. However, data on the use of medical or surgical abortion protocols across Switzerland is lacking. We report protocol characteristics in abortion care for two different facility types, hospital vs private practices (office-based) in Switzerland. Furthermore, we investigate an association between protocol characteristics and the likelihood of following through with the abortion at the same facility. We also report abortion outcomes of an office-based cohort where doctors use simplified abortion protocols. This study consists of two parts. (i) Between April and July, 2019, we collected data regarding medical and surgical abortion protocols of institutions offering abortions, in a nationwide survey. We assessed whether the proportion of patients who followed through with the abortion (primary outcome) after first appointment was associated with predefined protocol characteristics, considered to complicate access to abortion services, using generalised estimating equations. (ii) We analysed abortion outcomes of six selected office-based facilities from January, 2008, to December, 2018, using simplified abortion protocols in accordance with the Worlds Health Organisation (WHO) guidelines. (i) We included a total of 39 institutions. Hospitals showed more protocol-based barriers to abortion access compared with office-based facilities. The odds of undergoing an abortion after the first appointment were increased using protocols with minimal barriers. Overall, office-based facilities applied higher gestational age limits, required fewer appointments, and administered mifepristone more often after the first visit than did hospitals. (ii) We included a total of 5274 patients with an incidence of complications requiring surgery of 2.5% in line with rates reported in published literature. Only a few hospitals provide abortion care with easy access to medical and surgical abortion, whereas most office-based facilities do. Access to abortion services is generally crucial, and should be provided in a single visit whenever clinically permissible.
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Affiliation(s)
| | - Stefanie von Felten
- Department of Biostatistics at Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Laura Perotto
- Department of Gyaecology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Romana Brun
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Denise Vorburger
- Department of Gynaecology, University Hospital Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
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Pearlman Shapiro M, Myo M, Chen T, Nathan A, Raidoo S. Remote Provision of Medication Abortion and Contraception Through Telemedicine. Obstet Gynecol 2023:00006250-990000000-00746. [PMID: 37054393 DOI: 10.1097/aog.0000000000005205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/23/2023] [Indexed: 04/15/2023]
Abstract
This Narrative Review describes the remote provision of family planning services, including medication abortion and contraception, through telemedicine. The coronavirus disease 2019 (COVID-19) pandemic was a catalyst to shift toward telemedicine to maintain and expand access to crucial reproductive health services when public health measures necessitated social distancing. There are legal and political considerations when providing medication abortion through telemedicine, along with unique challenges, even more so after the Dobbs decision starkly limited options for much of the country. This review includes the literature describing the logistics of telemedicine and modes of delivery for medication abortion and details special considerations for contraceptive counseling. Health care professionals should feel empowered to adopt telemedicine practices to provide family planning services to their patients.
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Affiliation(s)
- Marit Pearlman Shapiro
- University of Southern California, Los Angeles, and the University of California, San Diego, La Jolla, California; and the University of Hawaii, Honolulu, Hawaii
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Jung C, Oviedo J, Nippita S. Abortion Care in the United States - Current Evidence and Future Directions. NEJM EVIDENCE 2023; 2:EVIDra2200300. [PMID: 38320010 DOI: 10.1056/evidra2200300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Abortion Care in the United StatesAbortion services are a vital component of reproductive health care. Jung and colleagues review medication abortion and procedural abortion as well as implications of increasing restrictions on access in the United States.
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Affiliation(s)
- Christina Jung
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine
| | - Johana Oviedo
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine
| | - Siripanth Nippita
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine
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Moise KJ. Use of Rh Immune Globulin in First-Trimester Abortion and Miscarriage. Obstet Gynecol 2023; 141:862. [PMID: 36961969 DOI: 10.1097/aog.0000000000005134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Affiliation(s)
- Kenneth J Moise
- Department of Women's Health, Dell Medical School, University of Texas at Austin, and the Comprehensive Fetal Care Center, Dell Children's Medical Center, Austin, Texas
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42
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Masten M, Alston M. Treatment of Recurrent Cesarean Scar Pregnancy With Oral Mifepristone, Systemic Methotrexate, and Ultrasound-Guided Suction Dilation and Curettage. Cureus 2023; 15:e36200. [PMID: 37065359 PMCID: PMC10104687 DOI: 10.7759/cureus.36200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
Cesarean scar pregnancy (CSP), or pregnancies with implantation in a prior cesarean section scar, are rare but may be becoming more common with an increase in cesarean section deliveries. History of prior CSP may also increase the risk for recurrent CSP. Several treatment options and combinations of treatment options for CSP have been described in the literature. Although the optimal treatment is unclear, the Society of Maternal-Fetal Medicine published recommendation guidelines, which include recommendations for the treatment/termination of CSP pregnancies. Treatment of CSP is recommended with operative resection, ultrasound-guided suction dilation and curettage (D&C), or intragestational methotrexate with or without treatment modalities. This is a case report of a patient with recurrent CSP. Her first CSP was incorrectly diagnosed as an incomplete abortion after unsuccessful treatment with misoprostol alone and ultimately was successfully treated with systemic methotrexate. Her second CSP is the basis of this case report and was successfully treated with oral mifepristone and systemic methotrexate (50 milligrams/meter2) before an ultrasound-guided suction D&C at 10 weeks 1 day gestational age. The combination of mifepristone, systemic methotrexate, and suction D&C under ultrasound guidance as a treatment for recurrent CSP has not previously been described in published literature.
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Verma N, Grossman D. Self-Managed Abortion in the United States. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2023; 12:70-75. [PMID: 37305376 PMCID: PMC9989574 DOI: 10.1007/s13669-023-00354-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 03/09/2023]
Abstract
Purpose of Review This review aims to provide up-to-date information about self-managed abortion in the USA. Recent Findings Evidence indicates that there is growing demand for self-managed abortion in the USA as obstacles to facility-based care increase, especially since the Supreme Court overturned Roe v. Wade. Self-managed abortion with medications is safe and effective. Summary Based on a nationally representative survey, the lifetime prevalence of self-managed abortion in the USA in 2017 was estimated to be 7%. People experiencing barriers to abortion care, including people of color, people with lower incomes, people in states that have restrictive abortion laws, and those living farther from facilities providing abortion care are more likely to attempt self-managed abortion. While people may use a range of methods to self-manage abortion, there is growing use of safe and effective medications, including mifepristone used together with misoprostol and misoprostol used alone; use of traumatic and dangerous methods is rare. While many people attempt to self-manage their abortion because of barriers to facility-based care, others have a preference for self-care because it is convenient, accessible, and private. While the medical risks of self-managed abortion may be few, the legal risks may be significant. Sixty-one people have been criminally investigated or arrested between 2000 and 2020 for allegedly self-managing their abortion or helping someone else do so. Clinicians play an important role in providing evidence-based information and care to patients considering or attempting self-managed abortion, as well as minimizing legal risks.
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Affiliation(s)
- Nisha Verma
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA USA
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco (UCSF), 1330 Broadway, Suite 1100, Oakland, CA 94612 USA
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No-Test Medication Abortion: A Systematic Review. Obstet Gynecol 2023; 141:23-34. [PMID: 36701607 DOI: 10.1097/aog.0000000000005016] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/22/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To summarize the effectiveness and safety outcomes of medication abortion performed without prior pelvic examination or ultrasonogram ("no-test medication abortion"). DATA SOURCES We searched the MEDLINE, Scopus, Web of Science, Cochrane (including ClinicalTrials.gov), CINAHL, Global Index Medicus, and CAB Direct databases to identify relevant studies published before April 2022 using a peer-reviewed search strategy including terms such as "medication abortion" and "ultrasonography." We contacted experts in the field for unpublished data and ongoing studies. METHODS OF STUDY SELECTION We reviewed 2,423 studies using Colandr. We included studies if they presented clinical outcomes of medication abortion performed with mifepristone and misoprostol and without prior pelvic examination or ultrasonogram. We excluded studies with duplicate data. We abstracted successful abortion rates overall, as well as rates by gestational age through 63 days, 70 days and past 84 days. We abstracted complication rates, including the need for surgical evacuation, additional medications, blood transfusion, and ectopic pregnancy. TABULATION, INTEGRATION AND RESULTS We included 21 studies with a total of 10,693 patients with outcome data reported. The overall efficacy of no-test medication abortion was 96.4%; 93.8% (95% CI 92.8-94.6%) through 63 days of gestation and 95.2% (95% CI 94.7-95.7%) through 70 days of gestation. The overall rate of surgical evacuation was 4.4% (95% CI 4.0-4.9), need for additional misoprostol 2.2% (95% CI 1.8-2.6), blood transfusion 0.5% (95% CI 0.3-0.6), and ectopic pregnancy 0.06% (95% CI 0.02-0.15). CONCLUSION Medication abortion performed without prior pelvic examination or ultrasonogram is a safe and effective option for pregnancy termination. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021240739.
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Use of Rh Immune Globulin in First-Trimester Abortion and Miscarriage. Obstet Gynecol 2023; 141:219-222. [PMID: 36701622 DOI: 10.1097/aog.0000000000005017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/29/2022] [Indexed: 12/23/2022]
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Cárdenas-Suárez N, Ramirez-Santiago C, Zamora-Olivencia D, Romaguera J, Garcia Rivera EJ, Vale Moreno Y. Telehealth as a potential tool for outreach among women in Puerto Rico. AJOG GLOBAL REPORTS 2022; 3:100156. [PMID: 36691398 PMCID: PMC9860148 DOI: 10.1016/j.xagr.2022.100156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Access to the full spectrum of healthcare should be available to all individuals. After the revocation of the constitutional right to abortion, women have fewer alternatives to unplanned pregnancy. Telehealth provides an additional option for such pregnancies through its remote provision of services. This could benefit women of all social strata. However, data regarding telehealth among underserved populations are limited. OBJECTIVE This study aimed to evaluate the use of contraception, awareness of abortion services, and receptiveness to telehealth among women in Puerto Rico, a Spanish-speaking minority population. STUDY DESIGN This was a cross-sectional study of women living in Puerto Rico aged between 21 and 65 years. Data were collected with a self-administered survey via SurveyMonkey from March to December of 2021. Recruitment was done through social media and at the gynecology clinics of the University of Puerto Rico, Medical Sciences Campus and San Juan City Hospital. Analysis was done with Stata, version 14.2. Chi-square and Cochran-Armitage tests were used to evaluate the unadjusted relationship between variables. A P value ≤.05 was considered statistically significant. RESULTS A total of 286 women were recruited. Of these, 73.3% (189/258) were sexually active, 89.1% (229/257) were heterosexual, and 62.7% (163/260) were not using contraception. In addition, 63.3% (157/248) knew about emergency contraception, yet 42.4% (103/243) were unaware of any sources of access to it; 76.6% (197/257) were unaware of nearby abortion services. A higher education level was associated with knowing about emergency contraception (P<.05) and awareness of sources of access to it (P<.05). However, no significant association was found between a higher education level and awareness of nearby abortion services (P=.799). Regarding telehealth, 65.2% (176/270) were willing to use the service for future gynecologic visits, yet only 18.9% (51/269) were offered telehealth services. No association was found between previous telehealth experiences and willingness to use telehealth for future gynecologic visits (P=.325). CONCLUSION The lack of contraceptive use and unawareness of nearby abortion services place women at increased risk of unplanned pregnancy and unsafe practices. The gap between knowledge about and access to emergency contraception also calls for action. Telehealth may be of benefit given that most women showed interest in using it, and could be used for educating and providing women in Puerto Rico with contraception and medical abortions, further increasing their access to reproductive healthcare. Clarifying misconceptions and instructing women about safe practices is essential to our role as physicians. Ensuring women's access to adequate services is also vital for upholding their rights to healthcare.
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Affiliation(s)
- Natalia Cárdenas-Suárez
- Department of Obstetrics and Gynecology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico (Drs Cárdenas-Suárez, Ramirez-Santiago, Romaguera, Garcia Rivera, and Vale Moreno)
- Department of Obstetrics and Gynecology, San Juan City Hospital, San Juan, Puerto Rico (Drs Cárdenas-Suárez, Zamora-Olivencia, Romaguera, and Vale Moreno)
- Corresponding author: Natalia Cárdenas-Suárez, MD.
| | - Cayra Ramirez-Santiago
- Department of Obstetrics and Gynecology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico (Drs Cárdenas-Suárez, Ramirez-Santiago, Romaguera, Garcia Rivera, and Vale Moreno)
| | - Debora Zamora-Olivencia
- Department of Obstetrics and Gynecology, San Juan City Hospital, San Juan, Puerto Rico (Drs Cárdenas-Suárez, Zamora-Olivencia, Romaguera, and Vale Moreno)
- Department of Obstetrics and Gynecology, Bridgeport Hospital, Yale New Haven Health, Bridgeport, CT (Dr Zamora-Olivencia)
| | - Josefina Romaguera
- Department of Obstetrics and Gynecology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico (Drs Cárdenas-Suárez, Ramirez-Santiago, Romaguera, Garcia Rivera, and Vale Moreno)
- Department of Obstetrics and Gynecology, San Juan City Hospital, San Juan, Puerto Rico (Drs Cárdenas-Suárez, Zamora-Olivencia, Romaguera, and Vale Moreno)
| | - Enid J. Garcia Rivera
- Department of Obstetrics and Gynecology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico (Drs Cárdenas-Suárez, Ramirez-Santiago, Romaguera, Garcia Rivera, and Vale Moreno)
| | - Yari Vale Moreno
- Department of Obstetrics and Gynecology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico (Drs Cárdenas-Suárez, Ramirez-Santiago, Romaguera, Garcia Rivera, and Vale Moreno)
- Department of Obstetrics and Gynecology, San Juan City Hospital, San Juan, Puerto Rico (Drs Cárdenas-Suárez, Zamora-Olivencia, Romaguera, and Vale Moreno)
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Casas RS, Horvath SK, Schwarz EB, Bachorik AE, Chuang CC. Managing Undesired Pregnancy After Dobbs. J Gen Intern Med 2022; 37:4272-4275. [PMID: 36220947 PMCID: PMC9553298 DOI: 10.1007/s11606-022-07833-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 09/26/2022] [Indexed: 01/04/2023]
Abstract
Although both medication abortion (MAB) and aspiration procedures are safe and effective, the Supreme Court decision in Dobbs v. Jackson Women's Health Organization removed federal protection of access to abortion services. Abortion access is now illegal or severely limited in many states, leading to delays in abortion care for patients in all states. In this rapidly evolving landscape, primary care physicians (PCPs) must be familiar with laws surrounding abortion care in their own and neighboring states. PCPs must also be prepared to expedite abortion care by sharing resources, obtaining testing when needed, and counseling patients about expected outcomes following abortion.
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Affiliation(s)
- Rachel S Casas
- Division of General Internal Medicine, Department of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, USA.
| | - Sarah K Horvath
- Department of Obstetrics and Gynecology, Penn State Milton S. Hershey Medical Center, Hershey, USA
| | - Eleanor Bimla Schwarz
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, USA
| | - Alexandra E Bachorik
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, USA
| | - Cynthia C Chuang
- Division of General Internal Medicine, Department of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, USA
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Cao C, Zhou Q, Hu Z, Shu C, Chen M, Yang X. A retrospective study of estrogen in the pretreatment for medical management of early pregnancy loss and the inference from intrauterine adhesion. Eur J Med Res 2022; 27:129. [PMID: 35879721 PMCID: PMC9310452 DOI: 10.1186/s40001-022-00767-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 07/18/2022] [Indexed: 11/11/2022] Open
Abstract
Background Estrogen has been usually used in clinic for medical pretreatment of early pregnancy loss. There was little reported the effect of estrogen combined with prostaglandin analogs in the medical management of early pregnancy loss. This retrospective study aimed to evaluate the efficacy of estrogen pretreatment for medical management of early pregnancy loss and explore the confounding factor of intrauterine adhesion (IUA) on the outcome of medical management. Methods A total of 226 early pregnancy loss patients who received pretreatment with estradiol valerate and/or mifepristone, followed by carboprost methylate suppositories (study groups), or carboprost methylate suppositories alone (control group) in a regional central institution from March 2020 to February 2021 were retrospectively studied. All patients were evaluated by hysteroscopy 6 h after carboprost methylate suppositories use to assess whether the gestational sac was complete expulsion and assess the morphology of uterine cavity. Results The complete expulsion rate was 56.94% in the mifepristone and estradiol valerate-pretreatment group, 20.69% in the estradiol valerate-pretreatment group, 62.5% in the mifepristone-pretreatment group, and 12.5% in the control group. Compared with the control group, pretreatment with estradiol valerate did not increase the complete expulsion rate significantly (P = 0.297), pretreatment with mifepristone increased the complete expulsion rate significantly (P < 0.001). Pretreatment with mifepristone combined with estradiol valerate did not increase the complete expulsion rate significantly comparing with pretreatment with mifepristone (P = 0.222). The data of IUA showed that the complete expulsion rate in patients with IUA was lower than that in those patients without IUA (P < 0.001). Conclusions Pretreatment with estrogen was not a sensible substitute for mifepristone in the medical management of early pregnancy loss. Mifepristone followed by carboprost methylate suppositories was likelihood of the ideal medical scheme in early pregnancy loss. IUA decreased the complete expulsion rate of medical management, it is cautious about medical management for early pregnancy loss with risk of IUA. Trial Registration Number: ChiCTR2100046503. Date of registration (retrospectively registered): May 18, 2021. Trial registration website: http://www.chictr.org.cn/.
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Baraitser P, Free C, Norman WV, Lewandowska M, Meiksin R, Palmer MJ, Scott R, French R, Wellings K, Ivory A, Wong G. Improving experience of medical abortion at home in a changing therapeutic, technological and regulatory landscape: a realist review. BMJ Open 2022; 12:e066650. [PMID: 36385017 PMCID: PMC9670095 DOI: 10.1136/bmjopen-2022-066650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To inform UK service development to support medical abortion at home, appropriate for person and context. DESIGN Realist review SETTING/PARTICIPANTS: Peer-reviewed literature from 1 January 2000 to 9 December 2021, describing interventions or models of home abortion care. Participants included people seeking or having had an abortion. INTERVENTIONS Interventions and new models of abortion care relevant to the UK. OUTCOME MEASURES Causal explanations, in the form of context-mechanism-outcome configurations, to test and develop our realist programme theory. RESULTS We identified 12 401 abstracts, selecting 944 for full text assessment. Our final review included 50 papers. Medical abortion at home is safe, effective and acceptable to most, but clinical pathways and user experience are variable and a minority would not choose this method again. Having a choice of abortion location remains essential, as some people are unable to have a medical abortion at home. Choice of place of abortion (home or clinical setting) was influenced by service factors (appointment number, timing and wait-times), personal responsibilities (caring/work commitments), geography (travel time/distance), relationships (need for secrecy) and desire for awareness/involvement in the process. We found experiences could be improved by offering: an option for self-referral through a telemedicine consultation, realistic information on a range of experiences, opportunities to personalise the process, improved pain relief, and choice of when and how to discuss contraception. CONCLUSIONS Acknowledging the work done by patients when moving medical abortion care from clinic to home is important. Patients may benefit from support to: prepare a space, manage privacy and work/caring obligations, decide when/how to take medications, understand what is normal, assess experience and decide when and how to ask for help. The transition of this complex intervention when delivered outside healthcare environments could be supported by strategies that reduce surprise or anxiety, enabling preparation and a sense of control.
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Affiliation(s)
| | - Caroline Free
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Wendy V Norman
- Department of Family Practice, The University of British Columbia, Vancouver, British Columbia, Canada
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Maria Lewandowska
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Rebecca Meiksin
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Melissa J Palmer
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Rachel Scott
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Rebecca French
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Kaye Wellings
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Alice Ivory
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
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Mazer-Amirshahi M, Ye P. Toxicity of abortifacients: A review for physicians in the post roe era. Am J Emerg Med 2022; 61:7-11. [PMID: 36007432 DOI: 10.1016/j.ajem.2022.08.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/13/2022] [Accepted: 08/14/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND On June 24, 2022, the Supreme Court overturned Roe v. Wade, which will limit legal abortion in many areas of the U.S. Over half of abortions in the U.S. are performed using medication as opposed to surgical techniques. With widespread access to agents that are used for medication abortion, there may be an increase in emergency department presentations related to improper or unsupervised use of these medications. METHODS This narrative review focuses on the contraindications, adverse effects, and toxicities of the most common agents used for medication abortion in the U.S. RESULTS Medications included in this review are mifepristone, misoprostol, and methotrexate. Each of these medications has a unique adverse effect and toxicity profile. CONCLUSION Agents used for medication abortion have unique contraindications and adverse effects. Improper or unsupervised use may occur in the setting of limited abortion access and emergency medicine physicians are on the front lines in managing these presentations.
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Affiliation(s)
- Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC, United States of America; Georgetown University School of Medicine, Washington, DC, United States of America.
| | - Peggy Ye
- Georgetown University School of Medicine, Washington, DC, United States of America; Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC, United States of America
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