OBJECTIVE:The study's purpose was to determine the safety of two routes and doses of digoxin through assessment of systemic absorption, cardiac rhythm, and coagulation parameters injected as part of second-trimester dilation and evacuation abortion. METHODS:We randomized pregnant women between 19 and 23 weeks' gestation to receive either 1.5 mg digoxin through intra-amniotic injection (IAI) or 1.0 mg through intrathoracic injection (IFI). We measured subjects' serum digoxin levels and coagulation indices over 48 h post-injection and cardiac rhythm monitoring for 24 h. RESULTS:Ten patients in each group completed the study. All injections caused fetal demise within 24 h. In the IAI group, mean (±SD) digoxin peak concentration in the IAI group was 1.5. ±0.72 (range 0.7-2.9 ng/mL); in the IFI group 1.4 ± 0.74 ng/mL (range 0.5-2.4 ng/mL). Mean (±SD) time to peak digoxin level in the IAI group was 10.7 ± 8.5 h (range, 1-24 h); in the IFI group 1.5 ± 0.97 h (range, 1-4 h, p < 0.01). Five patients had laboratory-defined critical digoxin levels of uncertain significance. Cardiac rhythm monitoring showed no digoxin-associated rhythm or conduction abnormalities. Prothrombin and partial thromboplastin time levels remained normal in both groups. CONCLUSION:Neither 1.5 mg IAI nor 1.0 mg IFI of digoxin administered to induce fetal demise was associated with adverse maternal cardiac outcomes or coagulation parameter changes. Serum levels reflected significant digoxin absorption in both groups, generally resulting in maximum digoxin concentration peaks in the low therapeutic range. Injecting digoxin to cause fetal demise in abortion care appears safe and effective.

This document serves as a revision to the Society of Family Planning’s 2010 guidelines, integrating literature on new techniques and research and addressing the clinical, medical, and sociolegal questions surrounding the induction of fetal asystole. Insufficient evidence exists to recommend routine induction of fetal asystole before previable medication and procedural abortion. However, at periviable gestations and after fetal viability, inducing fetal asystole before abortion prevents the infrequent but serious occurrence of unanticipated expulsion of a fetus with cardiorespiratory activity (Best Practice). Defining viability is complicated as it represents a physiological continuum impacted by gestational duration along with multiple other individual clinical factors and circumstances; therefore, the exact gestational duration to offer fetal asystole will depend on the setting and clinical circumstances. If induction of fetal asystole before abortion is available, we recommend engaging in patient-centered counseling regarding the risks and benefits of induction of fetal asystole in the setting of each unique pregnancy scenario and the patient’s beliefs and priorities (Best Practice). We recommend that clinicians identify the optimal pharmacologic agent to administer for a given clinical scenario based on factors such as availability of each agent; the time frame in which fetal asystole needs to be established; and clinicians’ technical ability, preferences, and practice (Best Practice). Potassium chloride, lidocaine, and digoxin are all acceptable pharmaceutical agents to induce fetal asystole before abortion. To establish asystole rapidly, we suggest the use of potassium chloride (via intracardiac or intrafunic injection) or lidocaine (via intracardiac or intrafunic injection) (GRADE 2C), although intrathoracic administration of lidocaine may be acceptable. We recommend potassium chloride not be used if intracardiac or intrafunic location cannot be achieved to avoid the risk of accidental administration to the pregnant individual and because insufficient data support its efficacy via other intrafetal locations (GRADE 1C). When using digoxin, we recommend intrafetal administration (GRADE 1C), although intraamniotic administration may be acceptable depending on a clinician’s technical ability and setting. Because digoxin may take several hours to induce asystole, an alternative agent should be considered in settings where fetal asystole must be confirmed rapidly.

Introduction: The Centers for Disease Control and Prevention recommend considering screening asymptomatic women for trichomonas in high-prevalence settings. Whether urban abortion clinics constitute such a setting is unknown. Material and Methods: We offered trichomonas screening to patients presenting for abortion from October 2018 to February 2019 as a practice improvement and conducted a chart review. Results: Ninety-two percent (593/644) of patients underwent testing. Trichomonas prevalence was 10.0% (95% CI 7.7-12.6). Ninety five percent of patients diagnosed were treated. Testing only symptomatic patients would have missed 98% of infections. Conclusions: Trichomonas was highly prevalent, and universal testing and treatment was feasible in an urban abortion clinic. (C) 2021 Elsevier Inc. All rights reserved.

Although only 1.3% of abortions in the United States are between 20 and 24 weeks' gestation, these procedures are associated with elevated risks of morbidity and mortality. Adequate cervical preparation before dilation and evacuation (D&E) at 20-24 weeks' gestation reduces procedural risk. For this gestational range, at least one day of cervical preparation with osmotic dilators is recommended before D&E. The use of overnight osmotic dilators alone is sufficient for most D&Es at 20-24 weeks' gestation. Dilapan-S (R) dilators require a shorter time to achieve maximum dilation, may be more effective than laminaria and may increase the likelihood of success on the first D&E attempt. The use of adjunctive mifepristone administered one-day pre-operatively at the time of osmotic dilator placement, should be considered because evidence demonstrates that it makes D&E subjectively easier at 20-24 weeks without increasing side effects. While older studies suggest that two-days of serial osmotic dilators provide greater dilation than one day of dilators, adjunctive mifepristone may be comparable to a second day of dilators. Adjunctive misoprostol administered on the day of D&E does not appear to affect initial cervical dilation and procedure time and compared with mifepristone is associated with more side effects, such as pain and nausea. Using overnight mifepristone and same-day misoprostol without osmotic dilators at 20-24 weeks' gestation lengthens D&E procedure time and appears to increase immediate complications, at least among less experienced providers. Some evidence shows the feasibility of same-day cervical preparation before D&E at 20-24 weeks using Dilapan-S (R) with adjunctive misoprostol or serial repeat dosing of misoprostol, but same-day preparation should be limited to providers with significant experience with these regimens. The Society of Family Planning recommends preoperative cervical preparation before D&E at 20-24 weeks' gestation. Further studies are needed to clarify the best means of preparing the cervix in order to minimize abortion complications and improve outcomes in this gestational range. (C) 2020 Elsevier Inc. All rights reserved.

Although only 1.3% of abortions in the United States are between 20 and 24 weeks’ gestation, these procedures are associated with elevated risks of morbidity and mortality. Adequate cervical preparation before dilation and evacuation (D&E) at 20–24 weeks’ gestation reduces procedural risk. For this gestational range, at least one day of cervical preparation with osmotic dilators is recommended before D&E. The use of overnight osmotic dilators alone is sufficient for most D&Es at 20–24 weeks’ gestation. Dilapan-S dilators require a shorter time to achieve maximum dilation, may be more effective than laminaria and may increase the likelihood of success on the first D&E attempt. The use of adjunctive mifepristone administered one-day pre-operatively at the time of osmotic dilator placement, should be considered because evidence demonstrates that it makes D&E subjectively easier at 20–24 weeks without increasing side effects. While older studies suggest that two-days of serial osmotic dilators provide greater dilation than one day of dilators, adjunctive mifepristone may be comparable to a second day of dilators. Adjunctive misoprostol administered on the day of D&E does not appear to affect initial cervical dilation and procedure time and compared with mifepristone is associated with more side effects, such as pain and nausea. Using overnight mifepristone and same-day misoprostol without osmotic dilators at 20–24 weeks’ gestation lengthens D&E procedure time and appears to increase immediate complications, at least among less experienced providers. Some evidence shows the feasibility of same-day cervical preparation before D&E at 20–24 weeks using Dilapan-S with adjunctive misoprostol or serial repeat dosing of misoprostol, but same-day preparation should be limited to providers with significant experience with these regimens. The Society of Family Planning recommends preoperative cervical preparation before D&E at 20–24 weeks’ gestation. Further studies are needed to clarify the best means of preparing the cervix in order to minimize abortion complications and improve outcomes in this ges-

BACKGROUND: Adverse reproductive health outcomes are well documented among people experiencing homelessness or housing instability. Little is known about abortion outcomes among this population. OBJECTIVE: This study aimed to investigate the relationship between housing status and abortion outcomes and whether gestational age mediates this relationship. STUDY DESIGN: Our sample comprised 1903 individuals who had abortions at an urban clinic in San Francisco, CA, from 2015 to 2017. We defined homelessness or housing instability as a binary exposure, which included staying outside, with friends and/or family, or in a tent, vehicle, shelter, transitional program, or hotel. We evaluated gestational duration of >= 20 weeks as a mediator variable. Our primary outcome was any abortion complication. Logistic regression models were adjusted for age, race, substance use, mental health diagnoses, and previous vaginal and cesarean deliveries. RESULTS: Approximately 19% (n=356) of abortions were among people experiencing homelessness or housing instability. Compared with those with stable housing, people experiencing homelessness or housing instability presented later in pregnancy (mean gestational duration, 13.3 vs 9.5 weeks; P<.001) and had more frequent complications (6.5% vs 2.8%; P<.001; odds ratio, 2.2; 95% confidence interval, 1.2-3.9). Adjusting for race, substance use, mental health diagnoses, and previous cesarean deliveries, individuals experiencing homelessness or housing instability were more likely to have abortion complications (odds ratio, 2.3; 95% confidence interval, 1.3-4.0). However, the relationship was attenuated after adjusting for gestational duration (odds ratio, 1.4; 95% confidence interval, 0.7-2.6), suggesting that gestational duration mediates the relationship between housing status and abortion complications. CONCLUSION: Patients experiencing homelessness or housing instability presented later in gestation, which seems to contribute to the increased frequency of abortion complications.

The standard treatment for retained placenta is manual extraction, which can be very uncomfortable for women and require additional intravenous or regional analgesia. While ultrasound-guided instrumental removal of the placenta using Bierer forceps is standard practice for second-trimester abortion by dilation and evacuation, it has not been widely incorporated into practice after vaginal birth. The purpose of this study was to describe our experience and associated clinical outcomes with instrumental removal of the placental using Bierer forceps after vaginal birth. A retrospective cohort study of women with a retained placenta after vaginal birth who underwent placental removal either manually or with the Bierer forceps from 2013-2019 at two hospitals. Those whose placentas were unable to be removed by initial modality were then attempted with the other modality. We compared likelihood of successful removal and need for a second removal modality as well as complications associated with each technique using univariate analysis. 156 patients were included for analysis. 25 patients (16.1%) had initial attempt with Bierer forceps, and 131 (84.0%) had initial attempt with manual removal. 4 (16.0%) of patients initially treated with instrumental removal and 19 (14.5%) patients initially treated with manual removal required the second maneuver to successfully remove the placenta. Table 1 shows reasons why the initial maneuver was unsuccessful. Estimated blood loss was similar between the two groups (716.0 ml for manual removal vs 555.8ml for instrumental removal, p=0.9). The mean entire length of the third stage was 59 min (IQR 45-67) in those with initial instrumental removal and 49 min (IQR 15-45.5) in those with initial manual removal. There were no differences in complication rates between the two groups (Figure 1). The use of Bierer forceps is a safe, well tolerated, and effective option for removal of retained placenta at the time of vaginal delivery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

OBJECTIVE: To determine whether immediate initiation of oral contraceptive pills (OCPs) at the time of abortion improves continuation. To evaluate this, we compared immediate versus delayed initiation of OCPs after first-trimester aspiration and second-trimester dilation and evacuation. STUDY DESIGN: This is a randomized, single-blinded, controlled trial in which 295 women who chose OCPs as their contraceptive method were randomized to initiating OCPs either the same day as the abortion or the first Sunday following the abortion. Follow-up telephone surveys were administered at 2 and 6 months after abortion. Contraceptive continuation was evaluated per intent-to-treat analysis. RESULTS: A total of 295 women were randomized: 155 women to immediate and 140 to delayed initiation. Overall follow-up rates were 77% and 61% at 2 and 6 months, respectively. At 6 months, 57% of women in the immediate group and 66% in the delayed group were using OCPs (p =0.34). Eleven participants total (4 and 7 in the immediate and delayed arms, respectively) had become pregnant since their abortion (p =0.23). CONCLUSION: Immediate initiation of OCPs following abortion did not improve contraceptive continuation at 6 months.

Introduction: The benefit of inducing fetal demise before dilation and evacuation (D&E) remains unclear. Although one study demonstrated no effect on procedure time, some providers believe that inducing fetal demise makes the D&E quicker and may lead to fewer complications. The safety of D&E without inducing fetal demise is well established and a digoxin injection may pose unnecessary risks. We sought to evaluate the effect of inducing fetal demise on procedure duration for D&Es at 20 to 24 weeks.

Objective: To compare estimated versus measured blood loss at the time of dilation and evacuation (D&E). Study design: We measured blood loss for all D&E procedures between 16 and 24 weeks at one abortion clinic over 9 months. We weighed all blood-containing items and measured blood captured in the D&E tray. Providers recorded estimated blood loss before weighing or measuring blood. We compared median measured blood loss (MBL) and estimated blood loss (EBL) for each gestational week. Results: We measured blood loss in 371 of the 534 D&Es in the study period; we excluded 163 procedures because of failure to measure blood loss or contamination with amniotic fluid. Included and excluded procedures had similar median EBL5. Median EBL differed significantly from MBL for each week gestation from 16 to 24 weeks (p <=.001 for all comparisons); MBL was approximately twice as high as EBL for each gestational week. EBL and MBL increased with increasing gestation, as did the difference between EBL and MBL. Conclusion: Providers consistently and significantly underestimate blood loss at the time of D81. D&E providers may want to consider using a new heuristic for estimating blood loss. Implications: Providers significantly underestimate blood loss at the time of D&E. Future research should confirm these findings (particularly at 22-24 weeks gestation), evaluate the efficacy of interventions to improve estimations of blood loss, and determine best practices for decreasing blood loss. (C) 2018 Elsevier Inc. All rights reserved.

OBJECTIVE To estimate the incidence of pulmonary aspiration and other anesthesia-related adverse events in women undergoing dilation and evacuation (D&E) under intravenous deep sedation without tracheal intubation in an outpatient setting. METHODS We reviewed all D&Es done under anesthesiologist-administered intravenous deep sedation without tracheal intubation between February 2009 and April 2013. The study's primary outcome was pulmonary aspiration; secondary outcomes included other anesthesia-related complications. We calculated the incidence of anesthesia-related adverse events as well as a 95% CI around the point estimate. RESULTS During the 51-month study period, 4,481 second-trimester abortions were completed. Of these, 2,523 (56%) were done under deep sedation without tracheal intubation, 652 (26%) between 14 and 19 6/7 weeks of gestation, and 1,871 (74%) between 20 and 24 weeks of gestation. Seven cases of anesthesia-related complications were identified: two cases of pulmonary aspiration (0.08%, 95% CI 0.01-0.29%), four cases of upper airway obstruction (0.016%, 95% CI 0.04-0.41%), and one case of lingual nerve injury (0.04%, 95% CI 0.001-0.22%). CONCLUSION Deep sedation without tracheal intubation for women undergoing D&E has a low incidence of anesthesia-related complications.

Objective: To evaluate the efficacy of intramuscular methylergonovine maleate as prophylaxis against excessive bleeding when given after dilation and evacuation (D&E) at 20-24 weeks. Study design: We performed a randomized, double-blinded, placebo-controlled trial in patients without excessive bleeding requiring intervention after D&E completion. We administered study treatment within one minute of the end of the procedure. We primarily compared outcomes using a composite of indicators of excessive post-procedure blood loss (post-procedure measured blood loss exceeding 125 mL, uterine massage or compression for at least two minutes, administration of additional uterotonic medication, intrauterine balloon tamponade, uterine re-aspiration, blood transfusion, uterine artery embolization, hospital admission for bleeding, or major surgery). Secondary outcomes included individual indicator occurrences, satisfaction, and side effects. Results: From March 3, 2015 to March 31, 2017, we randomized 284 participants (n = 140 methylergonovine, n = 144 placebo), five before we registered the trial with clinicaltrials.gov. Baseline characteristics were similar between groups. The composite outcome occurred in 78 (56%) methylergonovine and 75 (52%) placebo participants (p = 0.5). Methylergonovine recipients required more intrauterine balloon use (n = 20 [14%]) versus placebo (n = 10 [7%]), p = 0.04. We also observed a non-significant trend towards more uterotonic administration (n = 56 [40%] versus n = 43 [30%], p = 0.07) and hospital admissions for bleeding (n = 4 [3%] versus n = 0, p = 0.06) in the methylergonovine group compared to placebo. Conclusion: We observed no improvement in the composite outcome for excessive bleeding with prophylactic post-procedure methylergonovine. In addition, individual excessive bleeding outcomes occurred more frequently in the methylergonovine group, potentially indicating harm with its prophylactic use after D&E. Implications: When administered prophylactically immediately after dilation and evacuation abortion at 20-24 weeks, methylergonovine increases uterine bleeding. Given the lack of data for effectiveness as a prophylactic agent and our findings indicating harm, we do not recommend its use for post-operative prophylaxis. (C) 2020 Elsevier Inc. All rights reserved.

CONTEXT:-Despite increased use of dilation and evacuation in the setting of fetuses with developmental anomalies, the pathology examination of fragmented specimens obtained by this technique has been understudied.OBJECTIVES:-To correlate pathologic findings in second-trimester fetal dilation and evacuation specimens with prenatal diagnoses established through ultrasound and/or chromosome studies to determine the value of pathology examination for supplementing or correcting clinical diagnoses.DESIGN:-In this retrospective study, clinical and pathology findings were correlated in 448 dilation and evacuation specimens performed for second-trimester termination of pregnancy for fetal anomalies discovered on ultrasound examination (278 cases) or chromosome analysis (170 cases).RESULTS:-In 109 of the 170 cases with chromosomal abnormalities (64%), pathologists identified at least 1 congenital defect associated with the respective karyotype. In 278 cases with ultrasound-detected anomalies, pathologists confirmed the major congenital defect in 116 fetal specimens (42%). Evaluating for congenital central nervous system and body wall/diaphragm pathologic findings proved challenging owing to tissue disruption. However, taking all categories into account, pathology studies corrected ultrasound diagnoses in 152 of 413 cases (37%) and yielded additional diagnostic findings in 137 cases (33%).CONCLUSIONS:-In a substantial number of cases, examination of fragmented fetuses corrected or refined prenatal diagnoses, demonstrating a role for detailed pathology examination of dilation and evacuation specimens in quality control of prenatal imaging studies and for potentially aiding subsequent genetic counseling.

Objective: To assess the association of clinician referral with decision-to-abortion time.Study design: We conducted a cross-sectional survey of women seeking abortion at all three Nebraska abortion clinics. We defined referral as direct (information for an abortion clinic), inappropriate (information for a clinic that does not provide abortions) or no referral. Women reported when they recognized their pregnancy, decided to seek abortion and contacted a clinician. The primary outcome decision-to-abortion time was time from certain decision to abortion. We used multivariate linear regression analysis, controlling for potential confounders.Results: Participants (n=356) were a mean of 26.8 +/- 5.3 years old, primarily white (62%), unmarried (88%) and urban (87%), with a mean gestational duration of 8(2/7) weeks (S.D.+/- 20 days). Forty-six percent (164) had contacted a clinician and 30% (104) had discussed abortion with one before their abortion. Of those, 30% received a direct referral, 6% received an inappropriate referral and 64% received no referral. Decision-to-abortion time did not vary by referral type [mean difference compared with direct referral: inappropriate referral, 1.1 days, 95% confidence interval (CI) -13.4 to 15.6, p=.88; no referral, 0.4 days, 95% CI -7.0 to 6.3]. The most common reasons cited for delay in obtaining an abortion were an inability to get an earlier appointment (105/263, 40%) and time needed to raise money to pay for the abortion (73/263, 28%).Conclusion: While neither occurrence of referral nor type was associated with decision-to-abortion times, women in Nebraska continue to face barriers to timely abortion care. (C) 2016 Elsevier Inc. All rights reserved.

ObjectiveWomen who have abortions are at high risk of contraception discontinuation and subsequent unintended pregnancy. The objective of this analysis was to identify factors associated with choice of highly effective, long-acting, progestin-only contraceptive methods after abortion.Study designWomen presenting for surgical abortion who selected the levonorgestrel intrauterine device (IUD), the progestin implant or the progestin injection (depot medroxyprogesterone acetate or DMPA) as their postabortion contraceptives were recruited to participate in a 1-year prospective cohort study. We used multivariable multinomial logistic regression to identify factors associated with choosing long-acting reversible contraceptives (IUD or implant) compared to DMPA.ResultsA total of 260 women, aged 18–45 years, enrolled in the study, 100 of whom chose the IUD, 63 the implant and 97 the DMPA. The women were 24.9 years old on average; 36% were black, and 29% were Latina. Fifty-nine percent had had a previous abortion, 66% a prior birth, and 55% were undergoing a second-trimester abortion. In multivariable analyses, compared with DMPA users, women who chose the IUD or the implant were less likely to be currently experiencing intimate partner violence (IPV); reported higher stress levels; weighed more; and were more likely to have finished high school, to have used the pill before and to report that counselors or doctors were helpful in making the decision (all significant at p<.05, see text for relative risk ratios and confidence intervals.) In addition, women who chose the IUD were less likely to be black (p<.01), and women who chose the implant were more likely to report that they would be unhappy to become pregnant within 6 months (p<.05) than DMPA users.ConclusionA variety of factors including race/ethnicity, past contraceptive use, feelings towards pregnancy, stress and weight were different between LARC and DMPA users. Notably, current IPV was associated with choice of DMPA over the IUD or implant, implying that a desire to choose a hidden method may be important to some women and should be included in counseling.ImplicationsIn contraceptive counseling, after screening for IPV, assessing patient’s stress and taking a history about past contraceptive use, clinicians should discuss whether these factors might affect a patient’s choice of method.

International Journal of Gynecology & ObstetricsVolume 129, Issue 1 p. 85-86 Brief communications Reproductive and gynecologic health after uterine artery embolization for postabortion hemorrhage Tami S. Rowen, Corresponding Author Tami S. Rowen [email protected] Division of Gynecology, Department of Obstetrics, Gynecology and Reproductive Science, University of California San Francisco, CA, USACorresponding author at: Division of Gynecology, Department of Obstetrics, Gynecology and Reproductive Science, University of California San Francisco, 2356 Sutter St. 5th floor, San Francisco, CA 94115, USA. Tel.: + 1 4158857788; fax: + 1 4153539550.Search for more papers by this authorJody Steinauer, Jody Steinauer Division of San Francisco General Hospital, Department of Obstetrics, Gynecology, and Reproductive Science, University of California San Francisco, CA, USASearch for more papers by this authorEleanor A. Drey, Eleanor A. Drey Division of San Francisco General Hospital, Department of Obstetrics, Gynecology, and Reproductive Science, University of California San Francisco, CA, USASearch for more papers by this authorAlexis Light, Alexis Light Tulane University School of Medicine, New Orleans, LA, USASearch for more papers by this authorMiles Conrad, Miles Conrad Department of Interventional Radiology, University of California San Francisco, CA, USASearch for more papers by this authorJennifer L. Kerns, Jennifer L. Kerns Division of San Francisco General Hospital, Department of Obstetrics, Gynecology, and Reproductive Science, University of California San Francisco, CA, USASearch for more papers by this author Tami S. Rowen, Corresponding Author Tami S. Rowen [email protected] Division of Gynecology, Department of Obstetrics, Gynecology and Reproductive Science, University of California San Francisco, CA, USACorresponding author at: Division of Gynecology, Department of Obstetrics, Gynecology and Reproductive Science, University of California San Francisco, 2356 Sutter St. 5th floor, San Francisco, CA 94115, USA. Tel.: + 1 4158857788; fax: + 1 4153539550.Search for more papers by this authorJody Steinauer, Jody Steinauer Division of San Francisco General Hospital, Department of Obstetrics, Gynecology, and Reproductive Science, University of California San Francisco, CA, USASearch for more papers by this authorEleanor A. Drey, Eleanor A. Drey Division of San Francisco General Hospital, Department of Obstetrics, Gynecology, and Reproductive Science, University of California San Francisco, CA, USASearch for more papers by this authorAlexis Light, Alexis Light Tulane University School of Medicine, New Orleans, LA, USASearch for more papers by this authorMiles Conrad, Miles Conrad Department of Interventional Radiology, University of California San Francisco, CA, USASearch for more papers by this authorJennifer L. Kerns, Jennifer L. Kerns Division of San Francisco General Hospital, Department of Obstetrics, Gynecology, and Reproductive Science, University of California San Francisco, CA, USASearch for more papers by this author First published: 05 December 2014 https://doi.org/10.1016/j.ijgo.2014.10.016Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References [1]Bartlett L.A., Berg C.J., Shulman H.B., Zane S.B., Green C.A., Whitehead S. et al. Risk factors for legal induced abortion-related mortality in the United States. Obstet Gynecol. 103 (4): 2004; 729–737 [2]Steinauer J.E., Diedrich J.T., Wilson M.W., Darney P.D., Vargas J.E., Drey E.A. Uterine artery embolization in postabortion hemorrhage. Obstet Gynecol. 111 (4): 2008; 881–889 [3]Haddad L., Delli-Bovi L. Uterine artery embolization to treat hemorrhage following second-trimester abortion by dilatation and surgical evacuation. Contraception. 79 (6): 2009; 452–455 [4]Berkane N., Moutafoff-Borie C. Impact of previous uterine artery embolization on fertility. Curr Opin Obstet Gynecol. 22 (3): 2010; 242–247 Volume129, Issue1April 2015Pages 85-86 ReferencesRelatedInformation

OBJECTIVES:Our survey aimed to characterize the practice of inducing fetal demise before pregnancy termination among abortion providers, including its technical aspects and why providers have chosen to adopt it.STUDY DESIGN:We conducted a survey of Family Planning Fellowship-trained or Fellowship-affiliated Family Planning (FP) subspecialists about their practice of inducing fetal demise, including questions regarding the circumstances in which they would induce demise, techniques used and rationales for choosing whether to adopt this practice.RESULTS:Of the 169 FP subspecialists we surveyed, 105 (62%) responded. About half (52%) of respondents indicated that they routinely induced fetal demise before terminations in the second trimester. Providers' practices varied in the gestations at which they started inducing demise as well as the techniques used. Respondents provided legal, technical and psychological reasons for their decisions to induce demise.CONCLUSION:Inducing fetal demise before second-trimester abortions is common among US FP specialists for multiple reasons. The absence of professional guidelines or robust data may contribute to the variance in the current practice patterns of inducing demise.IMPLICATIONS:Our study documents the widespread practice of inducing fetal demise before second-trimester abortion and further describes wide variation in providers' methods and rationales for inducing demise. It is important for abortion providers as a professional group to come to a formal consensus on the appropriate use of these techniques and to determine whether such practices should be encouraged, tolerated or even permitted.

OBJECTIVE:To evaluate the association between obesity (body mass index [BMI] 30 or higher) and dilation and evacuation (D&E) complications.METHODS:We conducted a retrospective cohort study of women who underwent D&E abortion from February 2009 to April 2013 at a hospital-based abortion practice in California. We evaluated the association between obesity and risk of complication after D&E using logistic regression. We defined complications a priori as cervical laceration, hemorrhage, uterine atony, anesthesia complications, uterine perforation, disseminated intravascular coagulation, and retained products of conception. We defined major complications as those requiring hospitalization, transfusion, or further surgical intervention.RESULTS:Complications occurred in 442 of 4,520 D&Es (9.8%), with equal proportions in obese and nonobese women (9.8%). Major complications occurred in 78 (1.7%) patients. After adjustment for age, ethnicity, prior vaginal delivery, prior cesarean delivery, and gestational duration, there was no association between BMI and D&E complications. Any individual complication was associated with each additional week of gestation (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.3-1.4), prior vaginal delivery (OR 1.5, 95% CI 1.2-1.9) and prior cesarean delivery (OR 1.8, 95% CI 1.4-2.3). Major complications were associated with each additional week of gestation (OR 1.3, 95% CI 1.1-1.4) and cesarean delivery (OR 1.8, 95% CI 1.1-3.1).CONCLUSION:We found no association between obesity and D&E complications. Our findings are consistent with previous studies demonstrating that later gestational duration is associated with an increased risk of complications. Obesity may not warrant referral to a high-risk abortion center, particularly because referral-associated delay might increase the risk of complications.LEVEL OF EVIDENCE:II.

OBJECTIVE: To evaluate operative time after adjunctive misoprostol or mifepristone compared with overnight osmotic dilators alone for cervical preparation before dilation and evacuation at 16–23 6/7 weeks of gestation. METHODS: This double-blind, three-arm, multicenter, randomized trial compared overnight osmotic dilators alone, dilators plus 400 micrograms buccal misoprostol 3 hours preoperatively, and dilators plus 200 mg oral mifepristone during dilator placement for dilation and evacuation. Our primary outcome was dilation and evacuation operative time within two cohorts: 16–18 6/7 weeks of gestation (N=150) and 19–23 6/7 weeks of gestation (N=150). Three hundred women were required for 80% power to detect a 2-minute difference in operative time. Secondary outcomes included initial cervical dilation, side effects, physician satisfaction by Likert scale, and complications. RESULTS: Between February 2013 and February 2014 we randomized 300 women evenly across treatment arms. Group demographics were similar. We found no difference in operative time in either gestational cohort (early cohort [minutes]: 5.11±3.0 dilators alone, 4.99±3.3 misoprostol, 4.33±2.0 mifepristone, P=.34; late cohort [minutes]: 7.50±3.7 dilators alone, 7.62±5.4 misoprostol, 6.74±3.2 mifepristone, P=.53). In the early cohort, initial dilation was greater with misoprostol than dilators alone (2.4 compared with 2.0 cm, P=.007). Patients given misoprostol had significantly more pain, fever, and chills. In the late cohort, dilation and evacuation procedures were less difficult after mifepristone (4.1%, 95% confidence interval [CI] 0.0–9.6) than misoprostol (18.8%, 95% CI 7.7–29.8) or dilators alone (18.8%, 95% CI 7.7–29.8; P=.04). We had inadequate power to infer differences in complications: dilators alone (10%, 95% CI 4.2–16.0) compared with misoprostol (2%, 95% CI 0–4.7) compared with mifepristone (2%, 95% CI 0–4.8). CONCLUSION: Despite no difference in operative time, adjunctive mifepristone facilitates later dilation and evacuation compared with osmotic dilators alone and is better tolerated than misoprostol. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01751087. LEVEL OF EVIDENCE: I

The standard treatment for retained placenta is manual extraction, in which a hand is introduced inside the uterus to cleave a plane between the placenta and the uterine wall. For women without an epidural, the procedure is extremely uncomfortable and may require additional measures such as intravenous narcotics or regional anesthesia. Although ultrasound-guided instrumental removal of the placenta is standard practice as part of second-trimester abortion by dilation and evacuation and may be done at many institutions, especially after failed manual extraction, it has not yet been described in the literature as a technique following vaginal birth. Our experience with this technique is that it causes less discomfort to the patient than a traditional manual extraction, because the instrument entering the uterus is much narrower than a hand. With the patient in dorsal lithotomy, we locate the cervix and stabilize it either with fingers or a ring forceps on the anterior lip. We introduce Bierer ovum forceps into the uterus under direct ultrasound guidance. The Bierer forceps are preferred because of their long length, large head, and serrated teeth that allow for a firm, secure grip on the placenta. We grasp the placental tissue with the forceps and apply slow, gentle traction in short strokes, regrasping increasingly more distal areas of placenta as necessary to tease out the placenta. After 1-2 minutes, the placenta separates and can be pulled out of the uterus, usually intact. Our experience suggests that this technique is a well-tolerated option for women without an epidural who have a retained placenta. Further study is needed to quantify the amount of discomfort and anesthesia that can be avoided with this technique, as well as whether there is any change in the frequency of infectious complications or the necessity of postremoval curettage.