Feasibility of intra-amniotic digoxin administration by obstetrics and gynecology trainees to induce fetal demise prior to medical abortion beyond 20 weeks

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The effect of induced fetal demise on induction to expulsion interval during later medication abortion: A retrospective cohort

OBJECTIVES

To investigate the effect of induced fetal demise on the induction to expulsion interval during later trimester medication abortion.

STUDY DESIGN

This retrospective cohort was conducted at St. Paul's Hospital Millennium Medical College, Ethiopia. Later medication abortion cases that had induced fetal demise were compared to matching cases with no induced fetal demise. Data were collected by reviewing maternal charts and analyzed using SPSS version 23. Simple descriptive analysis, χ2 test, and multiple logistic regression analysis were used as appropriate. Odds ratio, 95% CI, and p-value<0.05 were used to present the significance of the findings.

RESULTS

A total of 208 patient charts were analyzed. Seventy-nine patients were provided with intra-amniotic digoxin, 37 patients were provided with intracardiac lidocaine, and 92 had no induced demise. The mean induction to expulsion interval was 17.8 hours in the intra-amniotic digoxin group, which is not statistically different than 19.3 hours in the intracardiac lidocaine and 18.5 hours in the group without induced fetal demise (p-value = 0.61). Expulsion rate after 24 hours was not statistically different among the three groups (5.1% in the digoxin group vs 10.6% intracardiac lidocaine group vs 7.8% in the no induced fetal demise group, p-value = 0.82). Multivariate regression analysis demonstrated that inducing fetal demise was not associated with successful expulsion at<24 hours (adjusted odds ratio [AOR] = 0.19, 95% CI, 0.03-1.29 and AOR = 0.62, 95% CI, 0.11-3.48, for digoxin and lidocaine, respectively) from induction.

CONCLUSIONS

In this study, inducing fetal demise using digoxin or lidocaine prior to later medication abortion was not associated with a reduction in the induction to expulsion interval.

IMPLICATIONS

During later medication abortion with mifepristone and misoprostol, inducing fetal demise may not be associated with a change in the length of the procedure. Induced fetal demise may be required for other reasons.

Second- and Third-Trimester Medical Abortion Providers and Services in 2019: Results from the Canadian Abortion Provider Survey

OBJECTIVES

Mifepristone became available in Canada in 2017. Updated national guidelines recommend its off-label use for second/third-trimester medical abortion (STMA/TTMA) by labour induction. The objective of this study was to explore STMA/TTMA provision in Canada and the role of mifepristone.

METHODS

We conducted a national, cross-sectional, web-based, self-administered, anonymized survey, available in English and French. The survey was distributed through health professional organizations and recruited physicians who provided abortion care in 2019. We used a modified Dillman technique to maximize participation. The survey included sections on workforce and clinical care, including mifepristone use. We used R statistical software to produce descriptive statistics.

RESULTS

Four hundred sixty-five clinicians responded to the survey, of whom 112 reported providing STMA and 63, TTMA, for a total of 115 respondents providing at least 1 of the 2 services. Two-thirds of respondents were general obstetrician-gynaecologists or family physicians and the remainder were maternal-fetal medicine subspecialists. The majority (64.7%) provided STMA/TTMA in an academic hospital, and 59.4% performed fewer than 5 STMAs (maximum 50) and 76.1%, fewer than 5 TTMA (maximum 15) in 2019. Fifty-nine percent of respondents reported having used mifepristone/misoprostol for STMA. Among mifepristone users, 48.6% used it for TTMA. Most required an indication beyond patient request to provide STMA/TTMA (82.1%/95.5%).

CONCLUSIONS

STMA/TTMA care is provided by multiple (sub-) specialties, and mifepristone has not yet been universally implemented. Our results will inform knowledge translation activities aimed at facilitating collaboration between STMA/TTMA providers and health policy and service delivery leaders and will further increase mifepristone use for STMA/TTMA in Canada.

Leaps ahead in law but not in practice: Why we need to train in second trimester abortion care

BACKGROUND

Abortion care has always been controversial, with health professionals worldwide continually working to offer well-rounded safe services. Key improvements in New Zealand since abortion law reform include the ability to self-refer, no formal certification under 20 weeks gestation, and change to the indications for abortion after 20 weeks. Nationally, we know that the second trimester abortion incidence is stable, and will therefore require an ongoing workforce to sustain the service.

AIMS

To document the current second trimester workforce for medical and surgical abortion in New Zealand, and examine their training and practice.

MATERIALS AND METHODS

Anonymous non-discriminatory snowball survey covering the domains of demographics, barriers to abortion care, abortion training, abortion provision and procedure specifics using Qualtrics software.

RESULTS

Eleven practitioners currently perform dilation and evacuation, and 33 wish to. Current providers have between zero and three other colleagues to assist them in service provision. Most learned by an informal apprenticeship model and operate relatively infrequently. There is variance in the cervical preparation and evacuation procedure as well as skillset and/or willingness for later gestations. Fifty-nine practitioners' units currently provide medical abortion, and 62 wish to. There is more coherence in the regime of medical abortion, although the availability of this is affected by gestation and location.

CONCLUSION

For most women requesting second trimester abortions, additional time, cost and stress is still very much the status quo. District Health Boards need to prioritise training and workforce planning to ensure the availability of this essential service.