Second-trimester surgical abortion practices in the United States

Society of Family Planning clinical recommendation: Prevention of infection after abortion and pregnancy loss

This Clinical Recommendation serves as a revision to the Society of Family Planning's 2010 Prevention of infection after induced abortion guidance. It examines infection risk, identifiable risk factors, and prophylactic measures for the prevention of infection associated with procedural and medication management of abortion and pregnancy loss to make evidence-based recommendations for the clinical care of patients. The following are the Society of Family Planning's recommendations: We recommend clinicians test and treat patients for gonorrhea and chlamydia at the time of abortion if there is (1) high clinical suspicion, (2) a positive diagnosis, or (3) the pregnant individual is under 25 years old and due for routine screening according to Centers for Disease Control and Prevention's guidelines; clinicians should not delay abortion while awaiting diagnosis or treatment (GRADE 1C). We recommend against screening for bacterial vaginosis before abortion (GRADE 1C). Since the rate of infection is low for nonprocedural abortion and the number needed to treat is high, coupled with inherent risks associated with antibiotic use, we recommend against the use of universal antibiotic prophylaxis in the setting of medication abortion, medication management of early pregnancy loss, or self-managed abortion (GRADE 1C). We recommend universal antibiotic prophylaxis for patients undergoing procedural abortion across all gestational durations (GRADE 1A). For procedural management of pregnancy loss, we recommend antibiotic prophylaxis (GRADE 1A). We recommend clinicians initiate antibiotic prophylaxis for procedural abortion and procedural management of pregnancy loss before instrumentation to maximize efficacy (GRADE 1B). Antibiotics should be given with adequate time for absorption, but data on the optimal timing for prophylaxis are lacking. In the setting of osmotic cervical dilator use, there is insufficient evidence to recommend for or against routine antibiotic prophylaxis before osmotic cervical dilator placement. We recommend discontinuing antibiotic prophylaxis after the procedure is completed (GRADE 1B). We recommend a single dose of doxycycline 200 mg orally or azithromycin 500 mg orally before a procedural abortion or procedural management of pregnancy loss (GRADE 1B). Metronidazole is a second-line option as it has evidence to suggest a prophylactic effect despite being less effective than doxycycline or azithromycin against aerobic bacteria. We recommend against the use of fluoroquinolones for prophylaxis in the setting of procedural abortion or procedural management of pregnancy loss due to the increased risk of side effects and complications (GRADE 1B). There is insufficient evidence to recommend for or against vaginal preparation with a local antiseptic solution or to recommend a specific vaginal preparation regimen before procedural abortion or procedural management of pregnancy loss.

Women's wellbeing as an empty declaration? A qualitative exploration of challenges in accessing termination of pregnancy due to fetal anomaly in Germany

BACKGROUND

The provision of prenatal testing through publicly funded healthcare systems, including non-invasive prenatal testing (NIPT), is frequently justified on the basis of supporting reproductive autonomy and informed choice. This includes decision-making around termination of pregnancy (TOP), including where it is due to a diagnosis of fetal anomaly (TOPFA). In Germany, TOP is regulated under the criminal code. However, it is exempt from punishment, if provided upon request from the woman up to 12 weeks after conception (14 weeks gestation) and following mandatory counselling. After this gestational stage, TOP may be provided where it is necessary to ensure the physical and mental wellbeing of the pregnant woman. However, there is a significant lack of clarity about how to interpret and apply this criterion. Fetal anomaly is often detected or confirmed after the time limit for TOP upon request has passed, which introduces uncertainty whether a fetal indication justifies legal access to TOP.

METHODS

This study explores attitudes towards TOP, experiences with decision-making and access, and the implications of the German legal and regulatory frameworks. It draws on a qualitative semi-structured interview study, conducted between 2021 and 2022. Participants were 20 German professionals who have experience or expertise regarding the provision of NIPT, as well as 7 women with experiences of pregnancy, reproductive decision-making and the offer of NIPT. Interviews were conducted in German, and then transcribed, translated, and analysed using thematic analysis.

RESULTS

Participants explored the importance of being able to access TOPFA; how the social positioning of TOP as a taboo procedure creates practical and psychosocial barriers to TOPFA access; the tension of who ultimately gets to make the decision about whether TOP can be provided; and how gestational time limits create emotional stress, frustrating informed decision-making and reproductive autonomy.

CONCLUSIONS

Our findings highlight that where prenatal testing is provided in the absence of guaranteed access to TOP, women's wellbeing becomes an empty declaration in German healthcare policy.

The impact of the SB 8 Texas abortion ban on pregnancy duration at time of abortion in a large volume Colorado clinic

OBJECTIVES

To assess changes in type of abortion, gestational duration, and changes in the proportion of out-of-state residents at a university-affiliated clinic in Denver, Colorado after Texas passed Senate Bill 8 (SB 8) that banned abortion after embryonic cardiac activity can be detected.

STUDY DESIGN

We reviewed records of all visits of patients obtaining an abortion ≤22 weeks and 6 days gestation between January 2019 and June 2022. We created two time periods: before SB 8 (January 2019-August 2021) and after SB 8 (September 2021-June 2022). We assessed changes in type of abortion, gestational duration, and the proportion of out-of-state residents. We determined the odds of a second-trimester abortion (≥13 weeks and 0 day) after SB 8 using logistic regression models adjusted for gravida, parity, age, and the proportion of out-of-state residents.

RESULTS

There were 3844 abortions: 2875 before and 969 after SB 8. Second trimester abortions increased from 16.8% to 24.4% for Colorado residents and from 19.5% to 33.5% for out-of-state residents (p < 0.001). The proportion of patients that were Texas residents increased from 1.2% to 17.7% after SB 8 (p < 0.001). The adjusted odds of a second trimester abortion nearly doubled overall (adjusted odds ratio [aOR] 1.86 95% CI 1.55-2.23) and for Colorado residents (aOR,1.76, 95% CI, 1.44-2.16, respectively), and more than doubled for out-of-state residents (aOR, 2.34, 95% CI,1.53-3.59).

CONCLUSIONS

Laws that ban abortion early in pregnancy delay care and increase abortions occurring later in pregnancy, not only for people forced to seek care out of state, but for residents of states with abortion access.

IMPLICATIONS

Our data suggests that abortion bans may increase wait times, gestational duration, and force people to travel great distances for care. As more states ban abortion or restrict abortion, surrounding states where abortion is protected may need to meet the needs of those traveling in addition to their in-state residents.

Weight and Procedural Abortion Complications: A Systematic Review

OBJECTIVE

To systematically assess the existing empiric evidence regarding a potential relationship between higher body weight and procedural abortion complications.

DATA SOURCES

EMBASE, MEDLINE, CINAHL, Web of Science, Google Scholar, and Clinicaltrials.gov were searched.

METHODS OF STUDY SELECTION

Our search identified 409 studies, which were uploaded to Covidence for review management; 133 duplicates were automatically removed. A team of two reviewers screened 276 studies, and a third reviewer resolved conflicts. Studies were included if they 1) consisted of peer-reviewed research published between 2010 and 2022, 2) were conducted in the United States, 3) included people with a higher body weight (body mass index [BMI] 30 or higher) in the study sample, and 4) assessed at least one outcome of procedural abortion safety stratified by a measure of body weight.

TABULATION, INTEGRATION, AND RESULTS

We extracted study data using Covidence and calculated an odds ratio for each study to facilitate the synthesis of results. Six studies assessing a total of 38,960 participants were included. No studies found a significant relationship between procedural abortion complications and higher body weight overall. Subgroup analysis from one study identified a significant increase in complications specifically among participants with BMIs higher than 40 who had second-trimester abortions. All studies used a retrospective cohort design and fulfilled Newcastle-Ottawa Scale criteria to be considered good quality. Studies varied in terms of clinical settings, patient populations, gestations assessed, clinician training levels, and care protocols.

CONCLUSION

Overall, higher body weight was not associated with an increased risk of procedural abortion complications in the included studies. The practice of referring patients undergoing procedural abortion with a higher body weight for hospital-based care is not based on recent safety evidence. On the contrary, this practice threatens the health of people with a higher body weight by potentially delaying their access to abortion care, extending their pregnancies into later gestations, and blocking their ability to access an abortion altogether.

Efficacy of pharmacologic hemorrhage prophylactics in second-trimester abortions: a systematic review

OBJECTIVE

This study aimed to evaluate prophylactic uterotonics, antifibrinolytic medications, and vasoconstrictive agents in the prevention of hemorrhage during second-trimester abortions.

DATA SOURCES

PubMed, Embase (Elsevier platform), Evidence-Based Medicine Reviews (Ovid platform), and Web of Science were searched from database creation to October 30, 2023.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials, cohort studies, case-control studies, and case series evaluating pregnant individuals (between 13 0/7 and 27 6/7 weeks of gestation) who underwent dilation and evacuation and received prophylactic uterotonics (methylergonovine, carboprost, oxytocin, or misoprostol), antifibrinolytic medications (tranexamic acid), or vasoconstrictive agents (vasopressin, lidocaine with epinephrine) were included in the study. The outcomes of interest included postprocedural bleeding, rate of medications to treat bleeding, blood transfusion, reoperation, and transfer to a higher level of care for hemorrhage.

METHODS

Of note, 2 authors independently screened the abstracts using the Systematic Review Data Repository. A third reviewer resolved discrepancies. The full text of accepted abstracts was retrieved and assessed for eligibility by 2 independent authors. Eligible studies were independently assessed for quality and bias by 3 authors. A consensus review resolved discrepancies.

RESULTS

Among 5834 abstracts screened, 11 studies met the inclusion criteria: 5 randomized controlled trials, 3 retrospective cohort studies, and 3 case series, totaling 3857 individuals. The paucity of studies combined with the heterogeneity of included trials precluded the performance of the meta-analysis. Of note, 4 studies evaluating misoprostol were of overall low-quality evidence and primarily assessed misoprostol's use for cervical dilation. Thus, its efficacy in bleeding prophylaxis remains unclear. Moreover, 2 high-quality trials evaluating oxytocin concluded that oxytocin use resulted in decreased blood loss, without a difference in interventions to control bleeding. Furthermore, 2 studies provided moderate-quality evidence that paracervical vasopressin use decreased blood loss, particularly at advanced gestational ages, but subsequent intervention outcomes were not assessed. High-quality evidence evaluating methylergonovine found that this medication increased blood loss at the time of the procedure.

CONCLUSION

Current evidence on hemorrhage prophylaxis at the time of dilation and evacuation supports the use of intravenous oxytocin or paracervical vasopressin to decrease procedural blood loss, without an associated decrease in transfusion rate or use of other interventions. Future research on outcomes by gestational age can identify subgroups with the potential to derive the most benefit.

Risk Factors for Failure of Second-Trimester Termination with Misoprostol as a Single Agent

Background: Understanding the potential risk factors for failure of pregnancy termination is crucial for informed clinical decision making. Such insights can assist clinicians in adjusting the dosage or route of various regimens, as well as in counseling patients and predicting the likelihood of successful outcomes. However, research on these risk factors has been limited, and existing studies have yielded inconsistent results. To address this gap, we conducted a study with a large sample size, focusing on identifying the potential risk factors for failure of second-trimester termination using misoprostol as a single agent, specifically between 14 and 28 weeks of gestation. Methods: A secondary analysis based on a database of second-trimester terminations was conducted. The inclusion criteria were a singleton pregnancy, gestational age between 14 and 28 weeks, an unfavorable cervix, no spontaneous labor pain, intact membranes, and termination with misoprostol alone. Potential risk factors for failure of termination, defined as no abortion within 48 h, were analyzed using univariate and multivariate analyses. Results: A total of 1094 cases were included in the analysis, consisting of 991 successful cases and 103 (9.4%) cases of failure. The significant risk factors for failure of termination included early gestational age, live fetuses, sublingual regimen of 400 mcg every 6 h, and high maternal pre-pregnancy BMI. Previous cesarean sections and lower Bishop scores tended to increase the risk but did not reach a significant level. Conclusions: Second-trimester termination with misoprostol as a single agent was highly effective, with a failure rate of 9.4%. The risk factors for failure included gestational age, fetal viability, misoprostol regimen, and maternal pre-pregnancy BMI, suggesting that these factors should be taken into consideration for second-trimester terminations with misoprostol.

Society of Family Planning Clinical Recommendation: Management of hemorrhage at the time of abortion

Hemorrhage after abortion is rare, occurring in fewer than 1% of abortions, but associated morbidity may be significant. Although medication abortion is associated with more bleeding than procedural abortion, overall bleeding for the two methods is minimal and not clinically different. Hemorrhage can be caused by atony, coagulopathy, and abnormal placentation, as well as by such procedure complications as perforation, cervical laceration, and retained tissue. Evidence for practices around postabortion hemorrhage is extremely limited. The Society of Family Planning recommends preoperative identification of individuals at high risk of hemorrhage as well as development of an organized approach to treatment. Specifically, individuals with a uterine scar and complete placenta previa seeking abortion at gestations after the first trimester should be evaluated for placenta accreta spectrum. For those at high risk of hemorrhage, referral to a higher-acuity center should be considered. We propose an algorithm for treating postabortion hemorrhage as follows: (1) assessment and examination, (2) uterine massage and medical therapy, (3) resuscitative measures with laboratory evaluation and possible reaspiration or balloon tamponade, and (4) interventions such as embolization and surgery. Evidence supports the use of oxytocin as prophylaxis for bleeding with dilation and evacuation; methylergonovine prophylaxis, however, is associated with more bleeding at the time of dilation and evacuation. Future research is needed on tranexamic acid as prophylaxis and treatment and misoprostol as prophylaxis. Structural inequities contribute to bleeding risk. Acknowledging how our policies hinder or remedy health inequities is essential when developing new guidelines and approaches to clinical services.

Cervical preparation for second-trimester procedural abortion

PURPOSE OF REVIEW

To review the evidence-informed options for cervical preparation prior to second-trimester dilation and evacuation (D&E).

RECENT FINDINGS

As abortion restrictions increase and the number of abortion clinics and providers decreases, pregnant people are facing more barriers to abortion access. Those in need are now often required to travel for second-trimester abortion care, only to be faced with additional restrictions, such as mandatory waiting periods. Cervical preparation is recommended prior to D&E and takes time for effect. Given the increasing time required to obtain an abortion, patients and providers may prefer same-day cervical preparation to decrease the total time required. Options for same-day cervical preparation include misoprostol alone with single or serial doses, and misoprostol combined with osmotic dilators or transcervical balloon (Foley catheter). Same-day preparation may require additional clinical space to accommodate people after initiation of cervical preparation to manage side-effects and timing of the abortion. Overnight options are also used and more frequently later in the second trimester. Overnight options include mifepristone, osmotic dilators, and transcervical balloon and are often combined with same-day misoprostol. Medication alone preparation is well tolerated and effective in the second trimester, with the addition of mechanical methods with advancing gestation. With many options and combinations being safe and effective, providers can be dynamic and alter approach with supply shortages, adjust to different clinical settings, consider patient medical and surgical factors, and accommodate provider and patient preferences.

SUMMARY

Multiple pharmacologic and mechanical options have been shown to be safe and effective for cervical preparation prior to D&E. Consideration for multiple factors should influence the method of cervical preparation and methods may vary by patient, provider and setting.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Abortion providers in the United States: expanding beyond obstetrics and gynecology

In the years preceding the Dobbs v Jackson Women's Health Organization (2022) decision, there had been a shift in the demographics of abortion providers. Although most abortion providers were obstetricians-gynecologists, there had been a rapid increase in the number of internal medicine and family medicine physicians and advanced practice clinicians providing abortion care. As discourse about limiting abortion access has gained volume over the past few years, so have the number of legislative restrictions aimed at preventing people from seeking abortions. Among these are laws and policies targeted at reducing the number of providers and clinics providing abortion care, resulting in an absence of training, high case volume, and institutional restrictions. With the overturning of Roe v Wade, the landscape of abortion provision will continue to shift further. Action needs to be taken to expand the types of providers getting trained and providing abortions to ensure access for those seeking abortions.

Development and pilot testing of the 2019 Canadian Abortion Provider Survey

BACKGROUND

Substantial changes in abortion care regulations, available medications and national clinical practice guidelines have occurred since a 2012 national Canadian Abortion Provider Survey (CAPS). We developed and piloted the CAPS 2019 survey instrument to explore changes of the abortion provider workforce, their clinical care as well as experiences with stigma and harassment.

METHODS

We undertook development and piloting in three phases: (1) development of the preliminary survey sections and questions based on the 2012 survey instrument, (2) content validation and feasibility of including certain content aspects via a modified Delphi Method with panels of clinical and research experts, and (3) pilot testing of the draft survey for face validity and clarity of language; assessing usability of the web-based Research Electronic Data Capture platform including the feasibility of complex skip pattern functionality. We performed content analysis of phase 2 results and used a general inductive approach to identify necessary survey modifications.

RESULTS

In phase 1, we generated a survey draft that reflected the changes in Canadian abortion care regulations and guidelines and included questions for clinicians and administrators providing first and second trimester surgical and medical abortion. In phase 2, we held 6 expert panel meetings of 5-8 participants each representing clinicians, administrators and researchers to provide feedback on the initial survey draft. Due to the complexity of certain identified aspects, such as interdisciplinary collaboration and interprovincial care delivery differences, we revised the survey sections through an iterative process of meetings and revisions until we reached consensus on constructs and questions to include versus exclude for not being feasible. In phase 3, we made minor revisions based on pilot testing of the bilingual, web-based survey among additional experts chosen to be widely representative of the study population. Demonstrating its feasibility, we included complex branching and skip pattern logic so each respondent only viewed applicable questions based on their prior responses.

CONCLUSIONS

We developed and piloted the CAPS 2019 survey instrument suitable to explore characteristics of a complex multidisciplinary workforce, their care and experience with stigma on a national level, and that can be adapted to other countries.

Gabapentin as an adjunct for pain management during dilation and evacuation: A double-blind randomized controlled trial

OBJECTIVES

To assess the analgesic efficacy of preoperative gabapentin among patients undergoing dilation and evacuation (D&E) with moderate sedation.

STUDY DESIGN

We conducted a randomized, controlled, double-blind trial among patients undergoing same-day D&E at 14 to 19 weeks gestation under moderate sedation. We randomized participants 1:1 to gabapentin 600 mg or placebo after cervical preparation at least 1 hour prior to D&E. We assessed pain using a 100-mm visual analog scale before, during, and after the procedure. The primary outcome was postoperative recall of maximum procedural pain with a 13-mm a priori threshold for clinical significance. We standardized initial fentanyl and midazolam dosing. We assessed satisfaction with pain control, nausea, and vomiting via Likert scales and anxiety using a validated instrument.

RESULTS

We enrolled 126 participants and randomized 61 to gabapentin and 65 to placebo, with study medication administered a mean of 211 (SD 64) minutes preoperatively. Recall of maximum pain was 41 mm for gabapentin and 49 mm for placebo (p = 0.24). Gabapentin resulted in reduced pain during uterine aspiration (56 vs 71 mm, p= 0.003) compared to placebo, but not for any other time points. The gabapentin group had higher satisfaction (78% vs 65% very or somewhat satisfied, p= 0.01). Median fentanyl dose was lower in the gabapentin group (75 vs 100 mcg, p = 0.005). Midazolam dose, nausea, vomiting, and anxiety did not differ between groups. No serious adverse events occurred in the gabapentin group. Sedation reversal was not required.

CONCLUSIONS

The addition of gabapentin to moderate sedation during D&E did not result in lower maximum recalled procedural pain. Gabapentin resulted in reduced intra-operative pain during uterine aspiration and increased satisfaction with pain control.

IMPLICATIONS

Gabapentin reduces intraoperative pain and improves satisfaction with pain management when administered prior to second-trimester surgical abortion and may be considered as an adjunct to intravenous sedation. Moderate sedation may impair assessment and recall of pain. Additional research is needed to identify the most effective pain management regimens for D&E.

Society for Maternal-Fetal Medicine Consult Series #59: The use of analgesia and anesthesia for maternal-fetal procedures

Pain is a complex phenomenon that involves more than a simple physical response to external stimuli. In maternal-fetal surgical procedures, fetal analgesia is used primarily to blunt fetal autonomic responses and minimize fetal movement. The purpose of this Consult is to review the literature on what is known about the potential for fetal awareness of pain and to discuss the indications for and the risk-benefit calculus involved in the use of fetal anesthesia and analgesia. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we suggest that fetal paralytic agents be considered in the setting of intrauterine transfusion, if needed, for the purpose of decreasing fetal movement (GRADE 2C); (2) although the fetus is unable to experience pain at the gestational age when procedures are typically performed, we suggest that opioid analgesia should be administered to the fetus during invasive fetal surgical procedures to attenuate acute autonomic responses that may be deleterious, avoid long-term consequences of nociception and physiological stress on the fetus, and decrease fetal movement to enable the safe execution of procedures (GRADE 2C); and (3) due to maternal risk and a lack of evidence supporting benefit to the fetus, we recommend against the administration of fetal analgesia at the time of pregnancy termination (GRADE 1C).

Society for Maternal-Fetal Medicine Consult Series #59: The use of analgesia and anesthesia for maternal-fetal procedures

Pain is a complex phenomenon that involves more than a simple physical response to external stimuli. In maternal-fetal surgical procedures, fetal analgesia is used primarily to blunt fetal autonomic responses and minimize fetal movement. The purpose of this Consult is to review the literature on what is known about the potential for fetal awareness of pain and to discuss the indications for and the risk-benefit calculus involved in the use of fetal anesthesia and analgesia. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we suggest that fetal paralytic agents be considered in the setting of intrauterine transfusion, if needed, for the purpose of decreasing fetal movement (GRADE 2C); (2) although the fetus is unable to experience pain at the gestational age when procedures are typically performed, we suggest that opioid analgesia should be administered to the fetus during invasive fetal surgical procedures to attenuate acute autonomic responses that may be deleterious, avoid long-term consequences of nociception and physiological stress on the fetus, and decrease fetal movement to enable the safe execution of procedures (GRADE 2C); and (3) due to maternal risk and a lack of evidence supporting benefit to the fetus, we recommend against the administration of fetal analgesia at the time of pregnancy termination (GRADE 1C).

Abortion Care Beyond 13 Weeks' Gestation: A Global Perspective

The majority of abortions are performed early in pregnancy, but later abortion accounts for a large proportion of abortion-related morbidity and mortality. People who need this care are often the most vulnerable-the poor, the young, those who experience violence, and those with significant health issues. In settings with access to safe care, studies demonstrate significant declines in abortion-related morbidity and mortality. This review focuses on evidence-based practices for induced abortion beyond 13 weeks' gestation and post-abortion care in both high- and low-resource settings. We also highlight key programmatic issues to consider when expanding the gestational age for abortion services.

A single-blinded randomized controlled trial evaluating pain and opioid use after dilator placement for second-trimester abortion

OBJECTIVES

To compare pain levels and medication needs after placement of laminaria vs Dilapan-S, and after dilation and evacuation (D&E).

STUDY DESIGN

We conducted a single-blinded randomized control trial of patients undergoing D&E at 15 0/7 to 23 6/7 weeks gestation, randomizing to cervical preparation with laminaria or Dilapan-S. We compared pain levels and medication usage following dilator placement (5 minutes; 2, 4, and 8 hours; the following morning) and D&E (1, 4, 24, and 48 hours). Our primary outcome was median change from baseline pain, and secondary outcomes included maximum pain timing and overall narcotic use. We compared baseline characteristics, median pain increases and quantities of narcotics used.

RESULTS

We analyzed 67 participants with laminaria (n = 34) and Dilapan-S (n = 33). More Dilapan-S users had a prior vaginal delivery (n = 20, 60.6%) than laminaria users (n = 11, 32.4%), p = 0.02. Maximum median pain was not statistically different (Laminaria: +3.5 (interquartile range [IQR] +0.5, +6.5); Dilapan-S: +3 (IQR +1, +5); p = 0.42. Thirty-seven (63.8%) participants reported higher levels of pain following dilator placement than D&E. Overall, 26 (42.6%) participants used narcotics during their abortion episode, with no difference in median number of tablets between laminaria (2, range 1-8) and Dilapan-S (4.5, range 1-15) participants (p = 0.34).

CONCLUSIONS

Median pain increase did not differ in participants receiving laminaria or Dilapan-S for cervical preparation prior to D&E. The majority of patients will use a small amount of narcotics if available.

IMPLICATIONS

The lack of difference in pain between laminaria and Dilapan-S enhances the applicability of pain intervention research across dilator types. With over half of participants using a small amount of narcotics during their D&E episode, pain management should be individualized to patient needs.

Management of Postabortion Complications for the Emergency Medicine Clinician

Although induced abortion is generally a safe outpatient procedure, many patients subsequently present to the emergency department, concerned about a postabortion complication. It is helpful for emergency physicians to understand the medications and procedures used in abortion care in the United States to effectively and efficiently triage and treat women presenting with potential complications from an abortion. Furthermore, because many states are experiencing increased abortion restrictions that limit access to care, emergency medicine physicians may encounter more patients presenting after self-managed abortions, which presents additional challenges. This article reviews the epidemiology and background of abortion care, including the range of symptoms and adverse effects that are within the scope of an uncomplicated procedure. This review also offers a comprehensive overview of management of abortion complications, including algorithms for more common complications and descriptions of less common but more severe adverse events. The article concludes with a recognition of the social stigma and legal regulations unique to abortion care.

Opioid prescription for pain after osmotic dilator placement in abortion care: A randomized controlled trial

OBJECTIVE

To compare the overnight maximum pain scores after osmotic dilator placement prior to a dilation and evacuation (D&E) procedure in participants assigned to a prescription for ibuprofen alone or to ibuprofen plus oxycodone.

STUDY DESIGN

We conducted a nonblinded pragmatic, randomized controlled trial to evaluate pain management among women undergoing osmotic dilator placement prior to D&E. We randomly assigned 70 participants at 12 weeks 6 days to 23 weeks 6 days gestation to receive a prescription for ibuprofen alone, or ibuprofen plus oxycodone. We assessed pain using a numeric rating scale (NRS; scale 0-10) at the following time points: Baseline, dilator placement, 2 and 6 hours, and preoperatively, where we also asked participants their maximum pain score. The primary outcome was mean individual NRS pain score change from baseline to maximum pain score.

RESULTS

Maximum mean pain score (change from baseline) was 4.7 ± 2.9 in the ibuprofen group, and 6.5 ± 2.5 in the ibuprofen plus oxycodone group (p < 0.01). Participants in both groups reported highest NRS pain scores 2 hours after dilator placement, 3.9 ± 2.5 and 5.3 ± 2.6 respectively (p = 0.02). Average ibuprofen use in both arms was similar, and 81% of participants used at least 1 dose of ibuprofen after dilator placement. Of those randomized to prescription to ibuprofen plus oxycodone, only 51% used a dose of oxycodone.

CONCLUSIONS

Compared to participants randomized to receive a prescription for ibuprofen, those randomized to receive a prescription for ibuprofen plus oxycodone reported higher maximum overnight pain scores.

IMPLICATIONS

Participants receiving a prescription for ibuprofen alone had lower maximum overnight pain scores following osmotic dilator placement. Given that opioid prescriptions did not appear to reduce overnight pain, minimizing these prescriptions would avoid opioid exposure for patients undergoing D&E.

A randomized controlled trial of methylergonovine prophylaxis after dilation and evacuation abortion

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.

Society of Family Planning clinical recommendations: Cervical preparation for dilation and evacuation at 20-24 weeks' gestation

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 gestational range.

A factorial-design randomized controlled trial comparing misoprostol alone to Dilapan with misoprostol and comparing buccal to vaginal misoprostol for same-day cervical preparation prior to dilation & evacuation at 14 weeks 0 days-19 weeks 6 days gestation

OBJECTIVES

To compare procedure times following same-day cervical preparation using misoprostol 400 mcg alone or misoprostol 400 mcg plus hygroscopic dilators for dilation and evacuation (D&E) before 20 weeks gestation and to compare side effects of buccal and vaginal misoprostol administration.

STUDY DESIGN

We randomized women undergoing D&E at 14 weeks 0 days-19 weeks 6 days gestation to receive (1) hygroscopic dilators or not and (2) buccal or vaginal misoprostol using a 2 × 2 factorial design. We assessed two primary outcomes: (1) total procedure time, defined as time to insert hygroscopic dilators plus D&E time, and (2) side effects of misoprostol 4-6 h after initiation of cervical preparation using a 5-point Likert scale assessing nausea, emesis, diarrhea, chills and cramps.

RESULTS

We randomized 163 women and 161 completed the study. We completed all procedures in one day. Mean total procedure time was 14.0 and 10.8 min. with and without hygroscopic dilators (difference 3.2 minutes, 95% CI 1.7, 4.6). Mean D&E procedure time was 0.7 (95% CI -0.8, 2.1) min longer without hygroscopic dilators. Initial cervical dilation was 15.6 and 11.7 mm with and without hygroscopic dilators (difference 3.9 mm, 95% CI 3.1, 4.8). Participants receiving buccal misoprostol reported less chills (1.9) than women receiving vaginal misoprostol (2.3), p = 0.04.

CONCLUSIONS

Hygroscopic dilators with misoprostol requires more time and increases cervical dilation without shortening D&E time when used for cervical preparation 4-6 h prior to D&E before 20 weeks. Women receiving vaginal misoprostol may have more chills compared to buccal misoprostol.

IMPLICATIONS

Adding hygroscopic dilators to misoprostol for same day D&E procedures at less than 20 weeks gestation increases total intervention time without reducing D&E time and is less favored by patients. Clinical judgment requires balancing relative effectiveness with patient preference. Further studies should evaluate the side effect profile of vaginal misoprostol.