Mifepristone-induced abortion and vaginal bleeding in subsequent pregnancy

BackgroundThe aim of this study is to explore the effect of first-trimester mifepristone-induced abortion on vaginal bleeding in subsequent pregnancy.Study DesignThis observational cohort study was conducted during 1998–2001 at antenatal clinics in Beijing, Chengdu, and Shanghai, China. The study enrolled 4,931 women with one previous mifepristone-induced abortion, 4,925 women with no history of induced abortion, and 4,800 women with one previous surgical abortion and followed them through pregnancy and childbirth.ResultsThe rates of vaginal bleeding in pregnant women with a history of medical abortion, no abortion, and surgical abortion were 16.5%, 13.9%, and 17.3%, respectively. The women with medical abortion had a higher risk (adjusted relative risk (aRR)=1.17, 95% confidence interval (CI): 1.07, 1.29) of vaginal bleeding compared with those with no abortion but similar risk to prior surgical abortion. When the correlation between medical abortion and vaginal bleeding was examined by period, increased risk was observed only in the early period (<16 gestational weeks) (aRR=1.25, 95% CI: 1.12, 1.39). The comparison between subgroups of medical abortion and no abortion showed that the observed risks increased particularly in those with abortion at gestational age ≤7 weeks (aRR=1.33, 95% CI: 1.18, 1.49), those followed by a postabortion curettage (aRR=1.58, 95% CI: 1.37, 1.84) or complications (aRR=1.99, 95% CI: 1.67, 2.37). There was no difference between women with medical abortion and women with surgical abortion in the occurrence of vaginal bleeding for either period.ConclusionsOne previous mifepristone-induced abortion increased the risk of vaginal bleeding in early gestation period of subsequent pregnancy compared with no abortion, especially if abortion occurred before 7 weeks of gestation and was followed by a curettage or complications.     

Outcomes of suction curettage and mifepristone abortion in the United States. A prospective comparison study.

A prospective, nonconcurrent cohort analysis of 178 mifepristone/misoprostol and 199 suction curettage abortion subjects, ages > or = 18 years, with intrauterine pregnancies < or = 63 days estimated gestational age, was conducted to compare the outcomes of suction curettage abortion to those of medical abortion. The medical abortion subjects received 600 mg of mifeprisone orally, followed by 400 micrograms of oral misoprostol 2 days later. Surgical abortion subjects underwent electronic vacuum aspiration. All subjects were followed for 2 weeks or until the absence of clinical bleeding. Outcome measures included a successful abortion (complete abortion without a surgical intervention), duration of bleeding, and morbidity. Overall, 18.3% medical and 4.7% surgical patients failed their primary procedure and received an unanticipated suction curettage (RR 3.93, 95% CI 1.87, 8.29). Four mifepristone subjects required curettage for acute bleeding, nine to manage ongoing pregnancy, and five for incomplete abortion. Fourteen mifepristone and eight surgical subjects required curettage for persistent bleeding. The median time delay for therapeutic curettage was significantly longer in the medical abortion group (35 versus 8 days; Mann-Whitney U = 17.0, p = 0.008). Medical subjects experienced significantly longer bleeding (mean difference = 9.6 days, 95% CI 6.8, 12.4). No significant change in hemoglobin occurred in either group. Mifepristone patients reported significantly greater pain (77.1% vs 10.5%; RR 7.4, 95% CI 4.7, 11.5), and nausea or vomiting (68.6% vs 0.6%; RR 117.9, 95% CI 16.7, 834.7). Women receiving mifepristone/misoprostol are more likely to require an unplanned surgical intervention than women who undergo suction curettage. They experience more discomfort with their procedure and in the follow-up interval, bleed for a longer period, and remain at risk for surgical completion curettage for several weeks.     

Timing and indication for curettage after medical abortion in early pregnant women with prior uterine incision

Background

Termination of pregnancy is an important and necessary back-up method for family planning services in many countries. The combination of mifepristone and misoprostol is a widely used alternative to surgical evacuation of the uterus in early pregnancy; however, there are few reports about medical abortion in women with a prior uterine incision and few studies have described curettage occurring as part of the procedure and an indication for the intervention. Curettage in a prior uterine incision can increase operative complications. The purpose of this study was to investigate whether vaginal bleeding intervals, routine ultrasound scan and serum β-hCG test after medical abortion could accurately identify women with uterine scars who would require curettage.

Methods

Six hundred sixty-eight women with a uterine scar and at up to 49 days of gestation underwent a medical abortion with mifepristone and misoprostol. Each woman took 50 mg and 25 mg of mifepristone orally in the morning and in the evening, respectively, for 2 days and 600 mcg of misoprostol orally on the third day.

Results

Of the 668 women, 6 (0.9%) were lost to follow-up. The overall complete abortion rate was 91.7%; 55 women underwent curettage, including 2 women with heavy bleeding, 3 women with ongoing pregnancy and 34 women with incomplete abortion. The incomplete abortion rate was significantly greater in women with persistent bleeding lasting 21 days than in women with persistent bleeding lasting 14 days (p<.001), and the overall sensitivity and specificity of vaginal bleeding interval (21 days) were 97.1% and 75%, respectively. The incomplete abortion rate was also greater in women whose serum β-hCG was ≥500 IU/L than in women whose serum β-hCG was <500 IU/L (p<.001), and the overall sensitivity and specificity of serum β-hCG (≥500 IU/L) were 97.1% and 62.5%, respectively. Moreover, the incomplete abortion rate was greater in women with an endometrial thickness ≥15 mm than in women with an endometrial thickness <15 mm (p<.001), and the overall sensitivity and specificity of endometrial thickness (≥15 mm) were 94.1% and 75%, respectively. No complication occurred.

Conclusions

The combination of mifepristone and misoprostol was found to be a safe and effective method to terminate early pregnancy in women with a previous cesarean delivery. If a woman with a prior uterine incision experienced vaginal bleeding intervals ≥21 days and/or had a bilayer endometrial thickness ≥15 mm and/or serum β-hCG ≥500 IU/L after a medical abortion, then she should undergo curettage.     

Maternal outcomes of intimate partner violence during pregnancy: study in Iran

Objectives

To investigate the prevalence of intimate partner violence (IPV) against pregnant women and its relationship with adverse maternal outcomes, including preterm labour, abortion, caesarean section, antenatal hospitalization and vaginal bleeding, in the West Azerbaijan, Iran.

Study design

Cross-sectional design.

Methods

In total, 1300 pregnant women, aged 18–39 years, who were referred to hospitals in the Iranian cities of Miandoab and Mahabad in the province of West Azerbaijan in 2009–2010 were recruited for this study by a convenience sampling method. Participants were asked to share their experiences of IPV during pregnancy and adverse maternal outcomes.

Results

Of these pregnant women, 945 (72.8%) reported that they had experienced IPV during their last pregnancy. A significant association was found between IPV and preterm labour [adjusted odds ratio (adjOR) 1.54, 95% confidence interval (CI) 1.16–2.03], caesarean section (adjOR 11.84, 95% CI 6.37–22.02), antenatal hospitalization (adjOR 6.34, 95% CI 3.82–10.52) and vaginal bleeding (adjOR 1.51, 95% CI 0.9–2.3).

Discussion

This study demonstrated a high prevalence of IPV during pregnancy, and found that IPV was associated with adverse maternal outcomes including preterm labour, caesarean section, antenatal hospitalization and vaginal bleeding. This adds to the existing literature and can be used to inform healthcare practices in developing countries. Medical, health and surgical services for pregnant women should consider screening for IPV, and providers should be aware that IPV victims are at increased risk for adverse outcomes. Services should also develop links with the Battered Women's Movement; such programmes now exist in many countries.     

Simplified follow-up after early medical abortion: 12-month experience of a telephone call and self-performed low-sensitivity urine pregnancy test

Objective

The objective was to determine if simplified follow-up after early medical abortion, consisting of a telephone call 2 weeks after the procedure plus a self-performed low-sensitivity urine pregnancy (LSUP) test, was successful for screening for ongoing pregnancies in the year following its introduction as standard service.

Study design

A retrospective computerized database review of 1084 women at a hospital abortion service in Edinburgh, UK, who had a medical abortion (≤ 9 weeks) and went home to expel the pregnancy was performed. Women who screened ‘positive’ at telephone follow-up on the basis of ongoing pregnancy symptoms, scant bleeding or LSUP test result were scheduled for an ultrasound. The main outcome measures were the proportion of women scheduled for telephone follow-up successfully contacted and the proportion of ongoing pregnancies detected.

Results

A total of 943 women were scheduled for telephone follow-up. Ten women presented to the hospital before the time of the follow-up call. Of the remaining 933 women, 656 [70%, 95% confidence interval (CI) 67.7-73.2] were successfully contacted. Five hundred seventy-three (87%, 95% CI 84.5–89.7) of those contacted screened ‘negative’; no false negatives occurred. Eighty-three (13%, 95% CI 10.2–15.5) screened ‘positive,’ and of those, three had ongoing pregnancies. Of the 277 (30%, 95% CI 26.7–32.7) who were not contacted, two ongoing pregnancies occurred. The sensitivity of telephone follow-up with LSUP to detect ongoing pregnancy was 100% (95% CI 30.9%–100%), and specificity was 88% (95% CI 84.9%–90.1%). The negative predictive value was 100% (95% CI 99.1%–100%), and positive predictive value was 3.6% (95% CI 0.9%–10.9%).

Conclusion

A telephone call and LSUP test at 2 weeks are suitable as a standard method of follow-up for screening for ongoing pregnancy after early medical abortion.

Implications statement

For most women, a routine clinic follow-up after early medical abortion (to exclude ongoing pregnancy) can be replaced with a telephone call and a self-performed LSUP test at 2 weeks postprocedure.     

Initiators and promoters for the occurrence of screen-detected breast cancer and the progression to clinically-detected interval breast cancer

Background

The risk factors responsible for breast cancer have been well documented, but the roles of risk factors as initiators, causing the occurrence of screen-detected breast cancer, or promoters, responsible for the progression of the screen-detected to the clinically-detected breast cancer, have been scarcely evaluated.

A pilot study on the use of letrozole with either misoprostol or mifepristone for termination of pregnancy up to 63 days

Background

Letrozole is a third-generation selective aromatase inhibitor. Animal data suggested that it might be useful in medical abortion. We performed two pilot studies to assess the feasibility of using letrozole in combination with either mifepristone or misoprostol for termination of pregnancy up to 63 days.

Study Design

We recruited 40 subjects who requested legal termination of pregnancies up to 63 days. Medical abortion was performed with letrozole 7.5 mg daily for 2 days followed by 800 mcg vaginal misoprostol in 20 subjects and letrozole 7.5 mg combined with 200 mg mifepristone in another 20 subjects.

Results

The mean induction-to-abortion interval of the regimen of letrozole and misoprostol was 9.1 h (median 7.9 h, range 2.7–23.6 h). The complete abortion rate was 80% (95% CI: 56.3–94.3%). For those with gestation of ≤49 days, the complete abortion rate was 87.5% (14/16; 95% CI: 61.7–98.5%). The mean induction-to-abortion interval of letrozole combined with mifepristone was 90.1 h (median 93.4 h, range 66.0–121.2 h). The complete abortion rate was 71.4% (95% CI: 47.8–88.7%).

Conclusion

These preliminary results suggest that a regimen of letrozole and misoprostol may be useful in medical abortion, but the combination with mifepristone is less effective and takes longer. Randomized studies comparing letrozole and misoprostol to misoprostol alone are warranted.     

Pilot study on the use of repeated doses of misoprostol in termination of pregnancy at less than 9 weeks of gestation

Pregnancy was terminated by repeated doses of vaginal misoprostol in 20 women at a gestational age of less than 9 weeks. The women were given 800 g of vaginal misoprostol as an initial dose followed by 400 g of vaginal misoprostol every 3 h for 4 doses. Fourteen women (70%, 95% confidence interval: 48–85%) had a complete abortion. Two women (10%) had a missed abortion, and two (10%) had an ongoing pregnancy. Two women (10%) had an incomplete abortion. The interval between the first dose of misoprostol and the passage of tissue mass was 25.3±34.4 h (median: 15 h).The duration of vaginal bleeding was 23.6±20.4 days (median: 14 days). Side-effects were mild and there was no significant drop in hemoglobin level. Repeated doses of vaginal misoprostol may be an alternative for women who do not want surgical abortion and who live in an area where mifepristone is not available.     

Mifepristone-induced early abortion and outcome of subsequent wanted pregnancy

Follow-up information on subsequent pregnancies after mifepristone (RU486)-induced abortion is scarce. The authors examined whether one mifepristone-induced first-trimester abortion affects the outcome of a subsequent wanted pregnancy. In a study conducted in 1998-2001 at antenatal clinics in Beijing, Chengdu, and Shanghai, China, the authors enrolled 4,925 women with no history of induced abortion, 4,931 women with one previous mifepristone-induced abortion, and 4,800 women with one previous surgical abortion and followed them through pregnancy and childbirth. The adjusted odds ratio for preterm delivery in women with one mifepristone abortion compared with women with no abortion was 0.77 (95% confidence interval: 0.61, 0.98). Although the mean birth weight of infants born to women with mifepristone abortion was 33 g (95% confidence interval: 17, 49) higher than that of infants born to women with no abortion, the frequencies of low birth weight and mean lengths of pregnancy were similar. There were no significant differences in risk of preterm delivery, frequency of low birth weight, or mean infant birth weight in the comparisons of women with previous mifepristone abortion and women with surgical abortion. This study suggests that one early abortion induced by mifepristone in nulliparous women has no adverse effects on the outcome of a subsequent pregnancy.     

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.     

Unintended pregnancy and postpartum contraceptive use in women with and without chronic medical disease who experienced a live birth

Background

Maternal chronic medical disease and unintended pregnancies increase the risk of maternal and infant morbidity and mortality. Little is known regarding the relationship between chronic medical disease status and pregnancy intendedness or contraceptive use.

Study Design

We compared pregnancy intention and postpartum contraception use in women with and without chronic medical disease who experienced a live birth using data from the Florida Pregnancy Risk Assessment Monitoring System 2004–2005.

Results

Women aged ≥20 years with chronic medical disease were more likely to report that the index pregnancy was unintended (odds ratio [OR]=1.56, 95% confidence interval [CI] 1.28–2.03) and reported similar postpartum contraception nonuse (OR=0.85, 95% CI 0.60–1.19) compared to those without chronic medical disease. Women aged <20 years with chronic medical disease were less likely to report that the index pregnancy was unintended (OR=0.50, 95% CI 0.28–0.88) and reported similar postpartum contraception nonuse (OR=0.99, 95% CI 0.54–1.82) compared to those without chronic medical disease.

Conclusions

In our study population, age and chronic medical disease were associated with different risks of pregnancy intention in the index pregnancy. Women with and without chronic disease in both age groups reported similar postpartum contraception use.     

Use of combined oral contraceptives post abortion

Background

Providing combined oral contraceptives (COCs) following surgical or medical induced abortion offers women an opportune moment to initiate a reliable contraceptive method.

Study Design

We conducted a systematic review, searching MEDLINE and The Cochrane Library for articles in any language concerning COC use following spontaneous, induced (medical or surgical) or septic abortion, from 1966 through June 2008. Seven articles were identified and evaluated using the United States Preventive Services Task Force system.

Results

Immediate COC initiation after first-trimester medical or surgical induced abortion did not increase side effects or prolong vaginal bleeding compared with use of a placebo, copper-bearing intrauterine device (IUD), nonhormonal contraceptive method or COC initiation at a later time. Initiating COCs after first-trimester surgical abortion produced small increases in coagulation parameters compared with IUD use; although they are statistically significant, their clinical relevance is unlikely. No study examined second-trimester induced or spontaneous abortion, or septic abortion.

Conclusions

Evidence shows that COCs can be safely initiated immediately following surgical and medical abortion in the first-trimester of pregnancy.     

Low-dose mifepristone 200 mg and vaginal misoprostol for abortion.

The objectives of this study were to determine the effectiveness, side effects, and acceptability of one-third the standard 600 mg dose of mifepristone (200 mg) to induce abortion. A prospective trial at seven sites enrolled women > or = 18 years, up to 8 weeks pregnant, and wanting an abortion. The women received 200 mg mifepristone orally, self-administered 800 micrograms misoprostol vaginally at home 48 h later, and returned 1-4 days later for ultrasound evaluation. Surgical intervention was indicated for continuing pregnancy, excessive bleeding, persistent products of conception 5 weeks later, or other serious medical conditions. Of the 933 subjects, 906 (97%) had complete medical abortions, 22 had surgical intervention, two were protocol failures, and three were lost to follow up. Of the 746 subjects who had no or minimal bleeding before misoprostol, 80% bled within 4 h and 98% within 24 h of using misoprostol. By day 7, 95% of women had a complete abortion. Side effects were aceptable in 85% of subjects, and 94% found the procedure acceptable. Low-dose mifepristone followed by vaginal misoprostol was highly effective as an abortifacient.     

Intrauterine contraceptive insertion postabortion: a systematic review

Background

This review was conducted to evaluate the evidence regarding the safety and effectiveness of intrauterine device (IUD) insertion immediately following spontaneous or induced abortion.

Study Design

We searched MEDLINE databases for all articles (in all languages) published in peer-reviewed journals from January 1966 through March 2010 for evidence comparing immediate postabortion IUD insertion with either no IUD insertion, insertion at a different time, insertion following first-trimester compared with second-trimester abortion or copper IUD insertion compared with hormone-releasing IUD insertion postabortion. We used standard abstraction forms to summarize and assess the quality of the evidence.

Results

The search strategy identified a total of 990 articles, of which 19 met our inclusion criteria for this review. Studies comparing immediate postabortion IUD insertion with no IUD insertion found that both groups experienced similar rates of pain and infection and a similar number of bleeding days, but one study reported that women with copper IUD insertion experienced a greater amount of bleeding than women without IUD insertion after abortion. Results from studies comparing immediate postabortion IUD insertion and insertion at a time not associated with pregnancy did not report differences between the two groups in the duration of bleeding, pain, expulsions or pelvic inflammatory disease (PID). One study however reported a greater amount of bleeding and another reported more removals for medical reasons among women with postabortion IUD insertion. Evidence from studies that examined immediate vs. delayed postabortion insertion reported minimal differences in bleeding, pain, expulsion and PID between groups. Studies comparing immediate IUD insertion after first- vs. second-trimester abortion reported no difference in removals for pain and bleeding, and an increased risk of expulsion among those women who had insertions after second-trimester abortion. In addition, women with insertions immediately after abortions occurring later in the first trimester had higher expulsion rates than those with insertions after early first-trimester abortions. Studies examining women using a copper IUD compared with a hormone-releasing IUD reported inconsistent results, with one paper reporting more bleeding days in the copper IUD group and another finding higher rates of removal for bleeding in the progesterone-releasing IUD group.

Conclusion

Intrauterine device insertion immediately after abortion is not associated with an increased risk of adverse outcomes compared with use of other contraceptive methods or with no IUD insertion after abortion and compared with IUD insertion at times other than immediately after abortion. Intrauterine device expulsion rates, while generally low, were higher with insertions that occurred after later first-trimester abortion compared with after early first-trimester abortion and higher with IUD insertion after second-trimester abortion compared with after first-trimester abortion.     

Two routes of administration for misoprostol in the treatment of incomplete abortion: a randomized clinical trial

Background

This study was conducted to compare the safety, effectiveness and acceptability of 400 mcg sublingual misoprostol and 600 mcg oral misoprostol for treatment of incomplete abortion.

Study Design

We used an open-label randomized controlled trial conducted from July 2005 to August 2006 in a large tertiary level maternity hospital in Antananarivo, Madagascar, and a large tertiary level hospital in Chisinau, Moldova. Three hundred consenting women seeking treatment for clinically diagnosed incomplete abortion with uterine size ≤12 weeks since last menstrual period were randomized to misoprostol either 600 mcg orally or 400 mcg sublingually. The primary outcome measure was the complete resolution of clinical signs and symptoms of incomplete abortion without need for surgical intervention. Women were seen for follow-up on Day 7 and, if necessary, on Day 14 to assess abortion status. The study was powered to detect a 7% difference in efficacy with a total of 142 women required in each arm.

Results

Efficacy rates were 94.6% and 94.5%, for the oral and sublingual routes, respectively (RR: 1.00, 95% CI=0.95–1.06, p=.98). At 1 week follow-up, more than 80% of women had completed abortions (77.8% oral and 84.8% sublingual, p=.12). Mean pain scores were 2.95 and 3.04, respectively, for the oral and sublingual groups. Side effects included abdominal pain, bleeding, headaches and dizziness/weakness with no differences reported between the two groups. Acceptability and satisfaction were high for both routes and women indicated a preference for medical versus surgical treatment if ever needed in the future.

Conclusions

Both treatment regimens were very effective. Four hundred micrograms of sublingual misoprostol and 600 mcg oral misoprostol appear to have similar safety and effectiveness profiles when used for the treatment of incomplete abortion. A lower 400-mcg misoprostol dose may provide an alternative treatment option as well as have potential benefits in terms of cost.     

Delays in request for pregnancy termination: comparison of patients in the first and second trimesters

Background

Despite the availability of first trimester abortion services in urban settings, many women request abortion in the second trimester. We identified protective and risk factors associated with women who delay requesting abortions until the second trimester.

Study Design

The study was a cross-sectional survey of 247 patients requesting surgical abortion at an urban family planning clinic. Survey and medical records data were analyzed for associations between 18 risk factors and incidence of second trimester request.

Results

Thirty-two percent of subjects presented in the second trimester. Chi-square analyses revealed that first trimester participants were more often employed (p<.0001), privately insured (p=.01), or had previous abortions (p=.04). Second trimester patients were younger (p<.0001), more often primigravid (p=.04), experienced more difficulty financing the procedure (p<.0001) and finding a surgeon (p<.0001), traveled longer distances (p=.005), and more often feared the procedure (p=.03). Using multiple logistic regression, women requesting second trimester abortions were more likely to report: obstacles financing the abortion (OR 2.34, 95% CI 1.28-4.28); traveling long distances (OR 2.88, 95% CI 1.31-6.31); and fear (OR 2.45, 95% CI 1.17-5.17). These women were less often employed outside the home (OR 0.35, 95% CI 0.19-0.64).

Conclusions

Physicians and advocates must strive to reduce abortion costs, increase access to trained surgeons, and allay women's fears of abortion procedures.     

Feasibility of telephone follow-up after medical abortion

Background

This study was conducted to assess the feasibility of using telephone calls combined with high-sensitivity urine pregnancy testing as a primary method of follow-up after medical abortion.

Methods

We enrolled 139 women up to 63 days of gestation to receive mifepristone 200 mg orally and misoprostol 800 mcg vaginally or buccally, per their choice. Participants were contacted by phone one week after mifepristone administration and interviewed using standardized questions. If the subject or clinician thought the pregnancy was not expelled, the subject returned for an ultrasound examination. Otherwise, subjects performed high-sensitivity home urine pregnancy testing 30 days after the mifepristone and were called within 3 days of the test. Those with positive pregnancy tests returned for an ultrasound examination. Those with negative tests required no further follow-up.

Results

Six of the 139 (4.3%, 95% CI 1.6-9.1%) subjects presented prior to Phone Call 1 for an in-person visit. All 133 (100%, 95% CI 97.8-100%) subjects eligible for their first telephone follow-up were contacted. Eight of the 133 (6.1%, 95% CI 2.6-11.5%) women were asked to return for evaluation and all did so (100%, 95% CI 63.1-100%). Eight of the 133 women eligible for the 30 day phone call presented for an interim visit prior to the call. After 30 days, 116 of the 117 (99.1%, 95% CI 97.5-100%) eligible subjects were contacted. One subject was not reached for the day 30 phone call. Twenty-seven of the 116 (23.3%, 95% CI 15.6-31.0%) subjects had a positive pregnancy test and required follow-up. Two of these subjects (7.4%, 95% CI 1.0-24.2%) did not return for in-person follow-up. Two of the 116 (1.7%, 95% CI 0.2-6.1%) subjects had inconclusive pregnancy tests and were asked to return for follow-up. One of these subjects (50%, 95% CI 1.2-98.7%) did not return. Complete follow-up was achieved in 135 of the 139 subjects (97.1%, 95% CI 94.3-99.9%). None of the 26 women evaluated for a positive or inconclusive pregnancy test had a gestational sac or continuing pregnancy.

Conclusion

Telephone follow-up combined with urine pregnancy testing after medical abortion is a feasible alternative to routine ultrasonography or serial serum hCG measurements.     

A comparison of transabdominal and transvaginal ultrasonography for determination of gestational age and clinical outcomes in women undergoing early medical abortion

Background

We sought to establish the accuracy of abdominal ultrasonography in determining gestational age and identifying the presence of a gestational sac and embryonic pole before and after medical abortion.

Methods

We included all 120 women enrolled in a study of simultaneous oral mifepristone and buccal misoprostol for abortion through 63 days' gestation. Vaginal and abdominal ultrasound examinations were performed before and 24 h after medication administration. Visualization of a gestational sac and embryonic pole and presence or absence of cardiac activity were recorded. Sensitivity and specificity were calculated with the results from vaginal ultrasonography as the gold standard. The effect of body mass index (BMI) on ultrasound findings was also assessed.

Results

Before treatment, the sensitivities of abdominal ultrasonography were 100% (95% CI 97-100) and 68% (95% CI 58-77) for presence of a gestational sac and an embryonic pole, respectively. Overall, abdominal imaging underestimated mean gestational age by 1.6 days (95% CI 1.0-2.2). After treatment, abdominal ultrasonography missed three of 34 retained gestational sacs (sensitivity 91%, 95% CI 76-98%). Fourteen women had gestational cardiac activity by vaginal ultrasound at follow-up. Abdominal imaging identified the gestational sac in all cases, but cardiac motion was only visible in 10 (71%, 95% CI 42-92%). For every 10-point increase in BMI, the odds ratio for missing an embryonic pole at baseline was 2.8 (95% CI 1.5-5.0).

Conclusions

Abdominal ultrasonography is sensitive for diagnosing the presence or absence of a gestational sac, but less sensitive at detecting an embryonic pole. This may lead to a small underestimation of gestational age and missing a continuing pregnancy at follow-up when one exists.     

The effect of immediate postpartum compared to delayed postpartum and interval etonogestrel contraceptive implant insertion on removal rates for bleeding

Objective

To determine whether the discontinuation rate of the etonogestrel contraceptive implant due to irregular vaginal bleeding among women with immediate postpartum insertion is increased compared to delayed postpartum and interval placement.

Study Design

This retrospective cohort study compared women who underwent immediate postpartum etonogestrel contraceptive implant insertion (within 96h of delivery) to delayed postpartum (6 to 12weeks postpartum) and interval insertion between January 2008 and December 2010. Charts were reviewed for date and reason for removal. A chi-squared test was used to compare discontinuation due to bleeding between cohorts. Baseline characteristics predictive of implant removal were evaluated by simple logistic regression.

Results

There were 259 women in the immediate postpartum group, 49 in the delayed postpartum group and 106 in the interval group. Average age at insertion was 22.6 (±5.5) years. Overall, 19.3% of women in the immediate postpartum group requested removal due to irregular bleeding compared to 18.4% in the delayed postpartum group [odds ratio (OR) 1.06, 95% confidence interval (CI) 0.48–2.33] and 20.8% in the interval group (OR 0.91, 95% CI 0.52–1.60). There was no difference between groups in premature removal rates for any side effect. There were no sociodemographic or clinical characteristics predictive of removal in any group.

Conclusion

One-fifth of etonogestrel contraceptive implant users requested premature removal due to irregular bleeding. Immediate postpartum implant insertion does not lead to increased removal rates and may help reduce unintended pregnancy. Mechanisms to help women manage irregular bleeding due to the implant are needed.

Implications

Immediate postpartum insertion of the etonogestrel contraceptive implant does not lead to increased removal rates due to vaginal bleeding compared to delayed postpartum or interval insertion. Immediate postpartum implant insertion may increase uptake of long-acting reversible contraception and help reduce short interpregnancy intervals and unintended pregnancy.