Buccal misoprostol plus laminaria for cervical preparation before dilation and evacuation at 21–23 weeks of gestation: a randomized controlled trial

Objective

To describe the effectiveness of buccal misoprostol as an adjunct to laminaria for cervical ripening before later second-trimester abortion by dilation and evacuation (D&E).

Methods

A randomized, double-blinded, placebo-controlled trial of 196 women undergoing D&E between 21 and 23 weeks of gestation. Subjects had overnight laminaria and 400 mcg buccal misoprostol or placebo 3–4 h before the abortion. We used logarithmic transformation of the primary outcome — D&E procedure duration — to achieve a normal distribution.

Results

Mean D&E duration was 1.7 min shorter with misoprostol (p=.02). The median duration was 9.7 versus 10.4 min in the misoprostol and placebo groups, respectively (p=.09). Cervical dilation was slightly greater with misoprostol (median 75 mm vs. 73 mm, p=.04); however, physicians did not find the misoprostol D&Es easier to complete. Half of subjects reported severe pain after misoprostol vs. 11% with placebo (p<.001).

Conclusion

Adjuvant buccal misoprostol results in slightly shorter D&Es at the cost of more side effects.     

Vaginal vs. sublingual misoprostol with mifepristone for cervical priming in second-trimester abortion by dilation and evacuation: a randomized clinical trial

Objectives

The study was conducted to assess the effectiveness of mifepristone 200 mg 48 h before administering misoprostol 600 μg, sublingual vs. vaginal route, prior to dilation and evacuation (D&E) in 12- to 20-week pregnancies.

Design

Randomized clinical trial.

Setting

Clínica Mediterrania Médica, Valencia, Spain.

Subjects

Women with 12- to 20-week pregnancies wanting a voluntary abortion between July 9, 2004, and February 9, 2006.

Methods

Nine hundred women were randomized to be included in one of the following four groups: (I) mifepristone 200 mg plus sublingual misoprostol 600 μg before D&E, (II) mifepristone 200 mg plus vaginal misoprostol 600 μg before D&E, (III) sublingual misoprostol 600 μg before D&E and (IV) vaginal misoprostol 600 μg before D&E.

Main Outcomes Measured

The degree of cervical dilation achieved before D&E, surgical time necessary to terminate the pregnancy and side effects of misoprostol.

Results

The average cervical dilation in the mifepristone groups was 12.5±2.8 mm (SD) [95% confidence interval (CI), 12.3-12.8] vs. 8.5±3.2 mm (SD) (95% CI, 8.2-8.8) in those receiving only misoprostol. Surgical time in the mifepristone sublingual misoprostol group was 11.9±4.3 min (SD) vs. 13.0±5.3 min (SD) in the sublingual misoprostol group without mifepristone (p=.007); in the mifepristone vaginal misoprostol group, the average surgical time was 12.3±5.0 min (SD) vs. 13.0±6.2 (SD) in the vaginal misoprostol group without mifepristone (p=.031).

Conclusions

Administering mifepristone before D&E with misoprostol in second-trimester abortions makes surgery easier and shorter and, to a certain extent, lessens the risk of cervical injuries, especially in D&E in advanced gestational periods.     

Surgical and medical second trimester abortion in South Africa: A cross-sectional study

Background

A high percentage of abortions performed in South Africa are in the second trimester. However, little research focuses on women's experiences seeking second trimester abortion or the efficacy and safety of these services.The objectives are to document clinical and acceptability outcomes of second trimester medical and surgical abortion as performed at public hospitals in the Western Cape Province.

Methods

We performed a cross-sectional study of women undergoing abortion at 12.1-20.9 weeks at five hospitals in Western Cape Province, South Africa in 2008. Two hundred and twenty women underwent D&E with misoprostol cervical priming, and 84 underwent induction with misoprostol alone. Information was obtained about the procedure and immediate complications, and women were interviewed after recovery.

Results

Median gestational age at abortion was earlier for D&E clients compared to induction (16.0 weeks vs. 18.1 weeks, p < 0.001). D&E clients reported shorter intervals between first clinic visit and abortion (median 17 vs. 30 days, p < 0.001). D&E was more effective than induction (99.5% vs. 50.0% of cases completed on-site without unplanned surgical procedure, p < 0.001). Although immediate complications were similar (43.8% D&E vs. 52.4% induction), all three major complications occurred with induction. Early fetal expulsion occurred in 43.3% of D&E cases. While D&E clients reported higher pain levels and emotional discomfort, most women were satisfied with their experience.

Conclusions

As currently performed in South Africa, second trimester abortions by D&E were more effective than induction procedures, required shorter hospital stay, had fewer major immediate complications and were associated with shorter delays accessing care. Both services can be improved by implementing evidence-based protocols.

     

Abortion barriers and perceptions of gestational age among women seeking abortion care in the latter half of the second trimester

Objective

Later second-trimester abortion (gestational age ≥ 19 weeks) is higher risk, more expensive and more difficult to access than abortion earlier in pregnancy. We sought to enumerate barriers to care described by women seeking abortion in the latter half of the second trimester. We also assessed the accuracy of later second-trimester abortion patients’ perceptions of their pregnancies’ gestational ages.

Study Design

A retrospective analysis of data from 232 women served by a referral program for women seeking abortion care between 19 and 24 weeks of gestational age was performed. Data collected included demographics, pregnancy history, gestational age by ultrasound, perceived gestational age, barriers to abortion care experienced and time lapsed from pregnancy recognition to presentation for care.

Results

Difficulty deciding whether to terminate (44.8%), financial barriers to care (22.0%) and the patient having recently realized she was pregnant (21.6%) were the most common delaying barriers cited. Nearly half (46.6%) of women underestimated their own gestational ages by greater than 4 weeks. Risk factors for experiencing at least 3 months time lapsed from pregnancy recognition to program referral included difficulty deciding whether to terminate [odds ratio (OR) 4.08, 95% confidence interval (CI) 2.51–8.70] and nonwhite race/ethnicity (OR 2.04, 95% CI 1.16–3.57).

Conclusions

Women seeking abortion care in the latter half of the second trimester encounter many of the same barriers previously identified among other abortion patient populations. Because many risk factors for delayed presentation for care are not amenable to intervention, abortion must remain available later in the second trimester.

Implications

Women presenting for abortion in the later second trimester are delayed by structural and individual-level barriers, and many substantially underestimate their own gestational age. Removing financial barriers may help reduce abortion delay; however, many risk factors are nonmodifiable, underscoring the need to ensure access to later second-trimester abortion.     

Intrauterine lidocaine for pain control during laminaria insertion: a randomized controlled trial

Objective

To determine if intrauterine administration of 5 cc of 2% lidocaine in addition to paracervical block reduces pain during laminaria insertion, when compared with paracervical block and saline placebo.

Study Design

This was a randomized, double blind placebo-controlled trial. Women presenting for abortion by dilation and evacuation (D&E) at 14–24 weeks gestational age were randomized to receive an intrauterine instillation of either 5 mL of 2% lidocaine or 5 mL of normal saline, in addition to standard paracervical block with 20 cc of 0.25% bupivacaine. Our primary outcome was self-reported pain scores on a 100 mm Visual Analogue Scale (VAS) immediately following laminaria insertion. Secondary outcome was self-reported VAS pain score indicating the maximum level of pain experienced during the 24–48-h interval between laminaria insertion and D&E procedure.

Results

Seventy-two women were enrolled, and data for 67 women were analyzed, only two of whom were more than 21 weeks on gestation. The range of pain scores at both time points was large (1–90 mm at laminaria insertion; 0–100 mm in laminaria–D&E interval). Mean pain scores were not different between treatment groups at laminaria insertion, (33 vs. 32, p=.8) or in the laminaria – D&E interval (43 vs. 44, p=.9).

Conclusion

Intrauterine administration of 5 cc of 2% lidocaine in addition to paracervical block did not reduce pain with laminaria insertion when compared to paracervical block with saline placebo.

Implications

Intrauterine lidocaine combined with paracervical block does not improve pain control at laminaria insertion when compared with paracervical block and saline placebo. Wide variation in pain scores and persistent pain after laminaria insertion suggests patient would benefit from more effective methods of pain control at laminaria insertion and during the post-laminaria interval.     

Insertion of intrauterine contraceptives immediately following first- and second-trimester abortions

Background

The study was conducted to assess the continuation and patient satisfaction with intrauterine contraception (IUC) insertion immediately after elective abortion in the first and second trimesters in an urban, public hospital-based clinic.

Study Design

A cohort of 256 women who elected to have insertion of a copper-T IUC (CuT380a) or a levonorgestrel-releasing IUC (LNG-IUC) were followed postoperatively by phone calls or chart review to evaluate satisfaction and continuation with the method.

Results

Of our 256 subjects, 123 had first-trimester abortions and 133 had second-trimester abortions (14 or more weeks). Median time to follow-up was 8 weeks (range 7-544 days). Nineteen discontinuations occurred: eight (6.5%, 95% CI 2.8-12.4%) following first-trimester and 11 (8.3%, 95% CI 4.2-14.3%) following second-trimester abortion (p=.6). Five women reported expulsion; one (0.8%, 95% CI 0.0-4.4%) in the first-trimester group and four (3.0%, 95% CI 0.8-7.5%) in the second-trimester group. (p=.4) Seven infections resulting in discontinuation occurred (2.7%, 95% CI 1.1-5.6%); none were positive for gonorrhea or chlamydia at time of insertion. No perforations occurred. Nearly all (93.8%) of the women were satisfied with IUC. Rates of satisfaction between women after first- and second-trimester abortions were equal.

Conclusion

In an urban clinic, IUC has high initial continuation and high patient satisfaction when inserted immediately following either first- or second-trimester abortions.     

Availability and characteristics of abortion training in US ob-gyn residency programs: a national survey

Objective

To assess the availability and characteristics of abortion training in US ob-gyn residency programs.

Methods

We surveyed fourth-year residents at US residency programs by email regarding availability and type of abortion training, procedural experience and self-assessed competence in abortion skills. We conducted multivariable, ordinal logistic regression with general estimating equations to determine individual-level and resident-reported, program-level correlates of quantity of uterine evacuation procedures done during residency.

Results

Three hundred sixty-two residents provided data, representing 161 of the 240 residency programs contacted. Access to training in elective abortion was available to most respondents: 54% reported routine training—where abortion training was routinely scheduled; 30% reported opt-in training—where training was available but not routinely integrated; and 16% reported that elective abortion training was not available. Residents in programs with routine elective abortion training and those who intended to do abortions before residency did a greater number of first-trimester manual uterine aspiration and second-trimester dilation and evacuation procedures than those without routine training. Similarly, routine, integrated training, even for indications other than elective abortion, correlated with more clinical experience (all p<.01, odds ratio and confidence interval shown below).

Conclusion

There is a strong independent relationship between routine training and greater clinical experience with uterine aspiration procedures.     

Obstetrician–Gynecologists and contraception: practice and opinions about the use of IUDs in nulliparous women,adolescents and other patient populations

Objectives

Use of intrauterine devices (IUDs) by US women is low despite their suitability for most women of reproductive age and in a variety of clinical contexts. This study examined obstetrician–gynecologists' practices and opinions about the use of IUDs in adolescents, nulliparous women and other patient groups, as well as for emergency contraception.

Design

A survey questionnaire was sent to a computer-generated sample of 3000 fellows who were reflective of the American College of Obstetricians and Gynecologists (College) membership.

Results

After exclusions from the 1552 returned surveys (51.7% response rate), 1150 eligible questionnaires were analyzed. Almost all obstetrician–gynecologists (95.8%) reported providing IUDs, but only 66.8% considered nulliparous women, and 43.0% considered adolescents appropriate candidates. Even among obstetrician–gynecologists who recalled reading a College publication about IUDs, only 78.0% and 45.0% considered nulliparous women and adolescents appropriate candidates, respectively. Few respondents (16.1%) had recommended the copper IUD as emergency contraception, and only 73.9% agreed that the copper IUD could be used as emergency contraception. A total of 67.3% of respondents agreed that an IUD can be inserted immediately after an abortion or miscarriage. Fewer (43.5%) agreed that an IUD can be inserted immediately postpartum, and very few provide these services (11.4% and 7.2%, respectively). Staying informed about practice recommendations for long-acting reversible contraception was associated with broader provision of IUDs.

Conclusions

Although most obstetrician–gynecologists offer IUDs, many exclude appropriate candidates for IUD use, both for emergency contraception and for long-term use, despite evidence-based recommendations.

Implications

This study shows that obstetrician–gynecologists still do not offer IUDs to appropriate candidates, such as nulliparous women and adolescents, and rarely provide the copper IUD as emergency contraception.     

Obstetrician–Gynecologists and contraception: long-acting reversible contraception practices and education

Objectives

Long-acting reversible contraception (LARC) — the copper and levonorgestrel intrauterine devices (IUDs) and the single-rod implant — are safe and effective but account for a small proportion of contraceptive use by US women. This study examined obstetrician–gynecologists' knowledge, training, practice and beliefs regarding LARC methods.

Design

A survey questionnaire was mailed to 3000 Fellows of the American College of Obstetricians and Gynecologists. After exclusions, 1221 eligible questionnaires were analyzed (45.8% response rate, accounting for exclusions).

Results

Almost all obstetrician–gynecologists reported providing IUDs (95.8%). Most obstetrician–gynecologists reported requiring two or more visits for IUD insertion (86.9%). Respondents that reported IUD insertion in a single visit reported inserting a greater number of IUDs in the last year. About half reported offering the single-rod implant (51.3%). A total of 92.0% reported residency training on IUDs, and 50.8% reported residency training on implants. Residency training and physician age correlated with the number of IUDs inserted in the past year. A total of 59.6% indicated receiving continuing education on at least one LARC method in the past 2 years. Recent continuing education was most strongly associated with implant insertion, and 31.7% of respondents cited lack of insertion training as a barrier.

Conclusions

Barriers to LARC provision could be reduced if more obstetrician–gynecologists received implant training and provided same-day IUD insertion. Continuing education will likely increase implant provision.

Implications

This study shows that obstetrician–gynecologists generally offer IUDs, but fewer offer the single-rod contraceptive implant. Recent continuing education strongly predicted whether obstetrician–gynecologists inserted implants and was also associated with other practices that encourage LARC use.     

Accompaniment of second-trimester abortions: the model of the feminist Socorrista network of Argentina

Objective

Legal restrictions on abortion access impact the safety and timing of abortion. Women affected by these laws face barriers to safe care that often result in abortion being delayed. Second-trimester abortion affects vulnerable groups of women disproportionately and is often more difficult to access. In Argentina, where abortion is legally restricted except in cases of rape or threat to the health of the woman, the Socorristas en Red, a feminist network, offers a model of accompaniment wherein they provide information and support to women seeking second-trimester abortions. This qualitative analysis aimed to understand Socorristas' experiences supporting women who have second-trimester medication abortion outside the formal health care system.

Acceptability and clinical outcomes of first- and second-trimester surgical abortion by suction aspiration in Colombia

Objective(s)

Since partial decriminalization of abortion in Colombia, Oriéntame has provided legal abortion services through 15 weeks gestation in an outpatient primary care setting. We sought to document the safety and acceptability of the second trimester compared to the first-trimester surgical abortion in this setting.

Study Design

This was a prospective cohort study using a consecutive sample of 100 women undergoing surgical first-trimester abortion (11 weeks 6 days gestational age or less) and 200 women undergoing second-trimester abortion (12 weeks 0 days–15 weeks 0 days) over a 5-month period in 2012. After obtaining informed consent, a trained interviewer collected demographic and clinical information from direct observation and the patient's clinical chart. The interviewer asked questions after the procedure regarding satisfaction with the procedure, physical pain and emotional discomfort. Fifteen days later, the interviewer assessed satisfaction with the procedure and any delayed complications.

Results

There were no major complications and seven minor complications. Average measured blood loss was 37.87 mL in the first trimester and 109 mL in the second trimester (p<.001). Following the procedure, more second-trimester patients reported being very satisfied (81% vs. 94%, p=.006). Satisfaction was similar between groups at follow-up. There were no differences in reported emotional discomfort after the procedure or at follow-up, with the majority reporting no emotional discomfort. The majority of women (99%) stated that they would recommend the clinic to a friend or family member.

Conclusions

Second-trimester surgical abortion in an outpatient primary care setting in Colombia can be provided safely, and satisfaction with these services is high.

Implications

This is one of the first studies from Latin America, a region with a high proportion of maternal mortality due to unsafe abortion, which documents the safety and acceptability of surgical abortion in an outpatient primary care setting. Findings could support increased access to safe abortion services, particularly in the second trimester.     

Doxycycline serum levels at the time of dilation and evacuation with two dosing regimens

Background

Doxycycline is commonly used for antibiotic prophylaxis before dilation and evacuation (D&E) but frequently causes nausea and emesis which may affect absorption and effectiveness. Taking doxycycline the night prior to surgery may result in adequate absorption with better tolerance.

Study Design

We enrolled 40 women into a double-blind randomized comparison of doxycycline 200 mg given 4 h before D&E (Group 1) vs. the night prior to D&E with dinner (Group 2). D&E procedures were scheduled after 11 a.m. and subjects were nil per os on the morning of the procedure. Subjects completed symptom diaries from dilator placement until the D&E. Serum for doxycycline assays was obtained before the D&E.

Results

Mean gestational age was 19.4 weeks (range 15.8-22.0 weeks) and did not differ by group. Serum was collected at 3.2 h (range 1.9-4.8 h) and 16.3 h (range 13.8-19.1 h) after ingestion of doxycycline in Groups 1 and 2, respectively. Median serum doxycycline levels (milligrams per liter) were 2.7 and 1.8 for Groups 1 and 2, respectively (p=.04). Emesis was experienced by 50% and 15% of women in Groups 1 and 2, respectively (p=.04). Nausea ratings were worse after doxycycline in the morning compared to doxycycline with dinner and compared to placebo at either time (all p<.01). Emesis following doxycycline consumption was not associated with lower doxycycline levels (p>.2).

Conclusion

When given with food on the night prior to D&E, doxycycline results in less emesis and nausea, but results in lower serum levels at the time of D&E.     

Pathways to unsafe abortion in Ghana: the role of male partners,women and health care providers

Background

Despite abortion being legal, complications from induced abortion are the second leading cause of maternal mortality in Ghana. The objective of this study was to understand the decision-making process associated with induced abortion in Ghana.

Study Design

Data were collected from female postabortion patients, male partners, family planning nurses and obstetricians/gynecologists at two teaching hospitals in Ghana using in-depth interviews and focus group discussions.

Results

While experiences differ for married and single women, men are involved in abortion decision making directly, through “orders” to abort, or indirectly, through denying responsibility for the pregnancy. Health care providers can be barriers to seeking safe abortions in this setting.

Conclusions

Women who choose to terminate a pregnancy without their male partners' knowledge should have the means (both financial and social) to do so safely. Interventions with health care providers should discourage judgemental attitudes and emphasize individually focused patient care.     

CD-ROM continuous medical education model for the management of urinary tract infections in family practice

Objectives

This study had for aim to assess the acceptability of a model for continuing medical education, to improve the implementation of best practice recommendations for family practice. The training focused on the management of community acquired urinary tract infections in adults. The secondary objective was to identify barriers in the implementation of these best practice recommendations.

Methods

We conducted a prospective qualitative study. The intervention included an initial knowledge test, an audio-visual CD-ROM presentation, and a second knowledge test. After the session, family practitioners (FP) were asked to answer a face-to-face questionnaire in order to give their opinion on the training session. Ten FP, working in the Savoie and Isère sub-divisions in France, were included.

Results

All FP were satisfied with the e-learning training session. The element of the session, they best appreciated, was the audio-visual presentation. The comparison between initial and second test results showed a non-significant improvement of knowledge (P = 0.07). The barriers, most frequently mentioned for knowledge and use of best practice recommendations, were: lack of time, content unfit for family practice, habits, and the very broad field of expertise required.

Conclusion

FP accepted this model of continuing medical education. E-learning seems relevant to improve the implementation of best practice recommendations in family practice.     

Change in abortion services after implementation of a restrictive law in Texas

Objectives

In 2013, Texas passed omnibus legislation restricting abortion services. Provisions restricting medical abortion, banning most procedures after 20 weeks and requiring physicians to have hospital-admitting privileges were enforced in November 2013; by September 2014, abortion facilities must meet the requirements of ambulatory surgical centers (ASCs). We aimed to rapidly assess the change in abortion services after the first three provisions went into effect.

Study design

We requested information from all licensed Texas abortion facilities on abortions performed between November 2012 and April 2014, including the abortion method and gestational age (< 12 weeks vs. ≥ 12 weeks).

Results

In May 2013, there were 41 facilities providing abortion in Texas; this decreased to 22 in November 2013. Both clinics closed in the Rio Grande Valley, and all but one closed in West Texas. Comparing November 2012–April 2013 to November 2013–April 2014, there was a 13% decrease in the abortion rate (from 12.9 to 11.2 abortions/1000 women age 15–44). Medical abortion decreased by 70%, from 28.1% of all abortions in the earlier period to 9.7% after November 2013 (p<0.001). Second-trimester abortion increased from 13.5% to 13.9% of all abortions (p<0.001). Only 22% of abortions were performed in the state's six ASCs.

Conclusions

The closure of clinics and restrictions on medical abortion in Texas appear to be associated with a decline in the in-state abortion rate and a marked decrease in the number of medical abortions.

Implications

Supply-side restrictions on abortion — especially restrictions on medical abortion — can have a profound impact on access to services. Access to abortion care will become even further restricted in Texas when the ASC requirement goes into effect in 2014.     

Delayed pregnancy testing and second-trimester abortion: can public health interventions assist with earlier detection of unintended pregnancy?

Background

Delayed pregnancy testing has been associated with presentation for abortion in the second trimester. Little is known about acceptability of potential interventions to hasten pregnancy recognition.

Study design

A total of 592 women presenting for abortion at six clinics in the United States completed surveys on contraceptive use, risk behavior, timing of first pregnancy test and interest in interventions to speed pregnancy recognition and testing.

Results

Forty-eight percent of women presenting for second-trimester abortion delayed testing until at least 8 weeks. In multivariate analysis, women who often spotted between periods had higher odds of delaying pregnancy testing [odds ratio (OR) 2.7, 95% confidence interval (CI) 1.04–6.94]. Women who often missed periods had higher odds of second-trimester abortion (OR 2.1, 95% CI 1.34–3.13). The majority (64%) of women were not aware of a fertile time in the menstrual cycle; these women had higher odds of second-trimester abortion (OR 2.0, 95% CI 1.21–3.37). Ninety-four percent of women expressed interest in at least one potential intervention to help recognize pregnancy earlier.

Conclusions

While there was near-universal interest in earlier pregnancy recognition, no single proposed intervention or scenario was endorsed by the majority. Improving sexual health awareness is an important consideration in future efforts to expedite pregnancy testing.

Implications

We found near-universal interest in earlier pregnancy recognition, though no single proposed intervention or scenario garnered majority support. Based on our findings, the concept of improving sexual health awareness through education should be incorporated in the development of future strategies to hasten recognition of unintended pregnancy.     

Second-trimester abortions in the United States

Late abortion remains a complex and difficult issue in the United States, where about 10 percent of all abortions are performed at 13 or more weeks' gestation. The reasons why women delay having abortions appear to be largely personal, and most are not amenable to public health intervention. Dilatation and evacuation (D&E) is the most frequently used method of second-trimester abortion, and the safest. Its greatest safety advantage lies in the 13-16-week-interval; for later abortions, D&E and instillation abortion have similar risks of complications and death. The rare instances in which an abortion procedure ends in a live birth represent the most controversial aspect of second-trimester abortion. However, trends toward abortions at earlier gestational ages, use of D&E and increased reliance on ultrasonography to confirm gestational age should reduce the frequency with which such events occur. Research in the area of midtrimester abortion should seek ways to reduce the need for such procedures, to improve their safety and to minimize the trauma of the experience for women.