Medical abortion and the risk of subsequent adverse pregnancy outcomes

Postabortion Contraceptive Utilization, Preferences, and Associated Factors among Women Receiving Abortion Care Services in Health Facilities of Ambo Town, Ethiopia

Background. The World Health Organization recommends the use of effective contraception for the prevention of unintended pregnancy and unsafe abortion. The main aim of postabortion contraceptive services is to prevent recurrent pregnancy and ultimately mitigate the associated maternal mortality. Objective. To assess postabortion contraceptive utilization (PACU) and postabortion contraceptive preferences (PACP) and the associated factors among women receiving abortion care services in Ambo town, Oromia Region, Western Ethiopia. Methods. A cross-sectional study was conducted at the health facilities in Ambo town from 22 July to 24 September 2021. The data was collected using a structured questionnaire. Bivariate and multivariable logistic regression was done to determine the factors associated with postabortion contraceptive utilization and preferences. Results. Out of 388 participants who were included in the final analysis, 262 (67.5%) had utilized postabortion contraceptives of which 173 (66%) received contraceptive methods of their primary preference. The multivariate logistic regression showed that cohabiting couples showed lower utilization ( $\text{AOR}=0.15$ ; 95% CI: 0.06-0.21; $p$ value = 0.004) than married ones and planning to have an additional child within 1-3 years ( $\text{AOR}=7.41$ ; 95% CI: 2.18-11.41; $p$ value = 0.005) or after 3-5 years ( $\text{AOR}=6.67$ : 95% CI: 5.12-10.18; $p$ value = 0.033) was identified to be significantly associated with postabortion contraceptive utilization. Having a secondary education level ( $\text{AOR}=3.06$ ; 95% CI: 1.54-6.07; $p$ value = 0.001) and having experience of domestic violence ( $\text{AOR}=2.19$ ; 95% CI: 1.27-3.81; $p$ value = 0.005) were significantly associated with unsatisfied postabortion contraceptive preference. Conclusions and Recommendations. About two-thirds of the women who were given abortion services received postabortion contraceptives whereas almost two-thirds of them received a contraceptive method of their primary preference. Marital status, duration before additional child planned, and being counseled on contraceptive determined postabortion contraceptive utilization. Having a secondary education level and having experienced domestic violence were significantly associated with unsatisfied PACP.

Danggui-Yimucao Herb Pair Can Protect Mice From the Immune Imbalance Caused by Medical Abortion and Stabilize the Level of Serum Metabolites

Unintended pregnancy is a situation that every woman may encounter, and medical abortion is the first choice for women, but abortion often brings many sequelae. Angelica sinensis Radix (Danggui) and Leonuri Herba (Yimucao) are widely used in the treatment of gynecological diseases, which can regulate menstrual disorders, amenorrhea, dysmenorrhea, and promote blood circulation and remove blood stasis, but the mechanism for the treatment of abortion is not clear. We determined the ability of Danggui and Yimucao herb pair (DY) to regulate the Th1/Th2 paradigm by detecting the level of progesterone in the serum and the expression of T-bet and GATA-3 in the spleen and uterus. Then, we detected the level of metabolites in the serum and enriched multiple metabolic pathways. The arachidonic acid pathway can directly regulate the differentiation of Th1/Th2 cells. This may be one of the potential mechanisms of DY in the treatment of abortion.

Subsequent placenta accreta after previous mifepristone-induced abortion: A case report

BACKGROUND

Mifepristone-induced abortion (MIA) has been used worldwide to terminate pregnancies. However, the association between placenta accrete (PA) and MIA has seldom been reported.

CASE SUMMARY

A 26-year-old pregnant woman presented with painless vaginal bleeding at 35 wk of gestation. She had a medical abortion (mifepristone followed by misoprostol) 1 year ago at the sixth week of gestation. Her personal history for previous surgery was negative. Abdominal ultrasonography showed a normal foetus with complete placenta previa. The foetal membrane ruptured with massive vaginal bleeding and severe abdominal pain. An emergency Caesarean section was performed, and the newborn was delivered. The placenta failed to expel and manual extraction was carried out. A large defect was noted in the uterine fundus and repair of the uterine rupture was conducted immediately. The postoperative pathology report showed placenta accreta.

CONCLUSION

The evidence suggests a possible etiologic role of MIA in PA, as the incidence of PA after MIA is much higher than general population. Millions of pregnancies are complicated by PA each year, some of which result in fatality. To prevent subsequent placental complications after MIA, hormonal supplementation might be a promising therapeutic options. However, further studies are needed to identify the high-risk factors and to confirm the effectiveness of estrogen supplement therapy.

Mandatory pre-abortion counseling is a barrier to accessing safe abortion services

Empirical research showcases that pre-abortion counseling scarcely reverses the woman’s decision either to terminate a pregnancy or not. Growing evidence regarding the high levels of decisional certainty among women seeking abortions renders a careful rethink of the place of mandatory pre-abortion counseling packages. Mandatory counseling packages, when inscribed in the laws, at times contain false information that can deter women from going in for safe abortions. Mandatory waiting times indirectly label opting for an abortion as not being the right thing to do. In areas where abortion stigma from health care providers and communities remains highly prevalent, women are forced to incur extra expenses by travelling to other countries. I argue that pre-abortion counseling on opting-in grounds is ethically sound (enhances the woman’s reproductive autonomy), since most clients in need of abortions are certain on their decisions before the abortion care provider and do not regret these decisions after the process. Regrets are prone to be more prevalent in areas with high unsafe abortion practices, generally due to complications from excessive bleeding, pain, and post abortion infections. Allowing systematic mandatory pre-abortion counseling practice as the rule in a competent adult is unjustified ethically and empirically, is time consuming and presents the legality of abortions in most settings an oxymoron.

Effects of sanitation practices on adverse pregnancy outcomes in India: a conducive finding from recent Indian demographic health survey

Background

Several risk factors predisposing women and their live-borns to adverse outcomes during pregnancy have been documented. Little is known about sanitation being a factor contributing to adverse pregnancy outcomes in India. The role of sanitation in adverse pregnancy outcomes remains largely unexplored in the Indian context. This study is an attempt to bring the focus on sanitation as a factor in adverse pregnancy outcome. Along with the sanitation factors, few confounder variables have also been studied in order to understand the adverse pregnancy outcomes.

Methods

The study is based on the fourth round of National Family Health Survey (NFHS-IV) covering 26,972 married women in the age-group 15–49. The study variables include the mother’s age, Body Mass Index (BMI), education, anemia, and Antenatal care (ANC) visits during their last pregnancy. The household level variable includes place of residence, religion, caste, wealth index, access to toilet, type of toilet, availability of water within toilet premises, and facility of hand wash near the toilet. Children study variables include Low Birth Weight (LBW), the order of birth (Parity), and the death of the children of the women in the last 5 years. The target variable Adverse Pregnancy Outcome (APO) was constructed using children born with low birth weight or died during the last pregnancy.

Results

We calculated both adjusted as well as unadjusted odds ratios for a better understanding of the association between sanitation and adverse pregnancy outcomes. Findings from the study showed that women who did not have access to a toilet within the house had a higher risk of adverse pregnancy outcome. In the multivariable model, no association was observed for adverse pregnancy outcome among women who did not have access to toilet and women who used shared toilet. Teenage (15–19 years), uneducated, underweight and anemic mothers were more likely to face APO as compare to other mothers in similar characteristics group.

Conclusions

Our findings contribute to the decidedly less available literature on maternal sanitation behaviour and adverse pregnancy outcomes. Our results support that sanitation is a very significant aspect for women who are about to deliver a baby as there was an association between sanitation and adverse pregnancy outcome. Education on sanitation practices is the need of the hour as much as it needs to follow.

Women’s experiences and acceptability of medical termination of pregnancy

Purpose

The purpose of this paper is to understand women’s experiences, acceptability and outcomes of using the medical termination of pregnancy (MTP). The study is conducted at nine reproductive health and family planning clinics at university hospitals as well as regional and provincial hospitals located in Bangkok and the locations within Thailand.

Design/methodology/approach

This is a descriptive research recruiting healthy women with pregnancy up to 63 days since the last menstrual period (LMP) who opted for MTP during 2012–2014.

Findings

A total of 443 women who were referred from the reproductive health networks voluntarily participated in the study. Overall, 92.6 percent of participants had a complete abortion. No serious adverse events were found for cases using misoprostol at home or at clinic. More than 98.3 percent of the women felt satisfied or very satisfied with the method. More than 80 percent of participants thought that the side-effects of the method were as expected or less than expected. More than 95 percent of the women recommended having MTP available in Thailand.

Originality/value

The introduction of MTP that uses a mifepristone and misoprostol regimen (Medabon®) in pregnancies up to 63 days, since LMP demonstrates that misoprostol can be safely used by women at home or at clinic. The administration of misoprostol at home reduces the number of hospital visits, which saves time and costs for traveling from home to the facility. In addition, women have more privacy and control over their bodies by self-administering misoprostol. The MTP’s introductory results also show that MTP service provision is well integrated into reproductive health and family planning services. It is useful for stakeholders who would be involved in design and planning of health system services before the MTP is made broadly available throughout the country.

Availability and prescription of misoprostol for medical abortion in community pharmacies and associated factors in Accra, Ghana

OBJECTIVE

To assess misoprostol availability at community pharmacies and determine factors affecting misoprostol prescription for medical abortion.

METHODS

A cross-sectional quantitative survey of randomly sampled community pharmacies and their corresponding pharmacists/pharmacy workers was conducted in the city of Accra, Ghana. Structured questionnaires were administered to collect data between May 1 and July 28, 2016. Descriptive statistics (frequencies and proportions) and bivariate and logistic regression analysis were used to analyze the data.

RESULTS

Of the 165 community pharmacies surveyed, approximately half (83 [50.3%]) stocked misoprostol. Availability of misoprostol however decreased when moving from first class to third class residential areas. 44 (26.7%) of the respondents had prescribed the drug at some time for medical abortion, but 140 (84.6%) indicated they would not prescribe the drug for medical abortion in future. Factors that significantly predicted misoprostol prescription for medical abortion included sex of the pharmacist/pharmacy worker, demand, and availability of misoprostol.

CONCLUSIONS

Demand for misoprostol for medical abortion was found to be high but only half of community pharmacies stocked it, and most pharmacy workers did not wish to prescribe the drug. If community pharmacies are to effectively contribute to expanding access to safe abortion services in Ghana, the disparity between misoprostol provision and demand needs to be addressed.

Medical abortions among university students in Ghana: implications for reproductive health education and management

Purpose

In Ghana, unsafe abortion is a major cause of maternal mortality. Even though pharmaceutical drugs seem to be a key means of unsafe abortion, a paucity of evidence exists on the issue among adolescents, students, and other groups at risk. This study therefore explores the abortion experiences of Ghanaian university students with particular reference to pharmaceutical drugs to fill the knowledge gap and enrich the evidence base for reproductive health education, policies, and interventions on abortions among students.

Patients and methods

Undergraduate students from the University of Ghana were randomly selected and interviewed. The interviews was recorded, transcribed, and analyzed thematically using the framework analysis.

Results

Students were aware of safe medical abortion services but were reluctant to use them because of cost, stigma, and proximity. Generally, medical abortions were more likely to be self-induced among students with misoprostol-based drugs administered orally or vaginally. However, students also used various over-the-counter drugs, contraceptives, and prescription drugs singly, in series, or in combinations to induce abortion. Yet students had relatively little knowledge on the inherent risks and long-term implications of unsafe medical abortions and were more likely to have repeat abortions through unsafe medical methods.

Conclusion

Students’ knowledge and awareness of safe medical abortion avenues have not influenced their propensity to use them because of stigma, cost, and other factors. Rather, several methods of unsafe medical abortions are used increasingly with dire long-term effects on students. Serious knowledge gaps exist among students on the methods and risks of medical abortion. Consequently, there is an urgent need to revise current abortion management approaches and redirect attention toward reducing stigma and financial and social costs of safe abortion services, and increasing the proactive engagement, counseling, and management of medical abortions among students.

Association of induced abortion with preterm birth risk in first-time mothers

Women who have previously had an induced abortion (IA) before their first birth have been associated with preterm birth (PTB). However, previous studies on the PTB are inconsistent. Therefore, the aim of this study was to clarify the association between IA and PTB and low birth weight (LBW) for first-time mothers. A total of 3,684 Southern Chinese women who gave birth for the first time to a live singleton infants were recruited between January 2015 and December 2015 in the province of Guangdong, China. Univariable and multivariable analyses were conducted to determine whether IA was associated with PTB and LBW. Previous IA was not associated with increased risks of PTB or LBW, adjusted odds ratios were 0.80 (95% CI = 0.53 to 1.20) and 0.86 (95% CI = 0.57 to 1.31), respectively. Additionally, no significant associations were observed for infants born at before 37, before 32, and before 28 gestational weeks. And no significant associations were also observed for LBW measuring lower than 2500 grams and also measuring lower than 1500 grams. Our study suggested that a previous IA, as compared with women who reported no previous IA, does not increase the risk of PTB or LBW in subsequent pregnancy for the first-time mothers among Southern Chinese women.

Risks of Adverse Perinatal Outcomes after Repeat Terminations of Pregnancy by their Methods: a Nationwide Register-based Cohort Study in Finland 1996-2013

BACKGROUND

Repeat terminations of pregnancy (TOPs) are associated with an increased risk of adverse outcomes in the subsequent birth. The perinatal outcomes after repeat TOPs by their methods have not yet been properly studied. This study aimed to examine perinatal outcomes in subsequent pregnancy among the women with a singleton birth and a history of TOPs.

METHODS

All the first-time mothers (n = 419 879) with a singleton birth during 1996-2013 in Finland were identified from the Medical Birth Register and linked to the Abortion Register. Adjusted multivariable logistic regression analysis was used to estimate risks of adverse perinatal outcomes.

RESULTS

The increased incidence of adverse perinatal outcomes was found with increasing number of surgical TOPs. After adjusting for confounders, the women with one surgical TOP had slightly increased but significant odds of 1.07 (95% CI 1.02, 1.13) for being small for gestational age compared with the women having no TOP. A significantly high risk for extremely preterm birth (OR 1.51, 95% CI 1.03, 2.23) was found among the women having had repeat surgical TOPs when compared to the women with no TOP. Non-significant risks were found for adverse perinatal outcomes after women's repeat surgical TOPs than repeat medical TOPs.

CONCLUSION

Information regarding the consequences of repeat induced TOPs will be significant in sexual health education as well as counselling women after first termination.

Perinatal outcomes after induced termination of pregnancy by methods: A nationwide register-based study of first births in Finland 1996-2013

Background

Women with previous terminations of pregnancy (TOPs) before their first birth have been associated with poorer perinatal outcomes. However, previous studies on the perinatal outcomes by the method in previous TOPs are inconsistent.

Objective

To examine the perinatal outcomes of the first-time mothers with singleton births, by the method of previous TOP (medical and surgical vs no TOP, and surgical vs medical).

Method

This is a nationwide register-based study including 419,879 first-time Finnish mothers with singleton birth during the time period 1996–2013. Mothers having their first birth were identified from the Medical Birth Register and linked to the Abortion Register by their identification numbers. Multinomial logistic regression analysis was performed to examine the risk for preterm birth, low birth weight, small for gestational age and perinatal death by the method in previous TOPs.

Results

Among the first-time mothers, 87.0% had no history of TOPs, 3.2% had a history of medical TOP(s), 9.2% had a history of surgical TOP(s) and 0.6% had a history of both (medical and surgical) TOP(s). No significant differences in perinatal outcomes were found among the women with surgical TOPs, compared to the women with no TOPs. In unadjusted analysis, increased odds for preterm birth and low birth weight were found when comparing women having previous surgical TOPs with medical TOPs. Even after the adjustment of potential confounders, odds for preterm birth < 37 weeks (OR = 1.19, 95% CI = 1.04–1.36) and low birth weight < 2500 g (OR = 1.16, 95% CI = 1.00–1.35) remained significant. After restricting data to the single TOP, the results were similar; OR for both preterm birth and low birth weight was 1.18 (95% CIs = 1.02–1.36 and 1.01–1.38).

Conclusion

Perinatal outcomes did not differ among the mothers with surgical TOPs compared to the mothers with no TOPs, while the outcomes were poorer after surgical TOP(s) than after medical TOP(s).

"I was close to death!": abortion and medical risk on American television, 2005-2016

OBJECTIVES

To examine the portrayal of complications and long-term health consequences associated with abortion on television, recognizing the impact that fictional stories can have on public beliefs about abortion's safety.

STUDY DESIGN

Using a systematic online search, we identified all instances of abortion on US television from 2005 to 2016. We qualitatively coded these plotlines to identify any occurrences of complications, interventions or long-term health consequences associated with abortion care, with 95% intercoder reliability. We calculated the frequencies and rates of these occurrences in Microsoft Excel.

RESULTS

Our search identified 80 abortion plot lines. A percentage of 37.5 of characters who obtained an abortion experienced complications, interventions and/or negative health consequences. This rate contrasts with the 2.1% of real patients who experience complications or require intervention as a result of their abortions. Most onscreen complications were major events (e.g., hemorrhage), as opposed to real women, whose complications are mostly minor. Major medical interventions (e.g., hysterectomy) were similarly overportrayed, while the most commonly used interventions for real patients (e.g., medication) were not depicted at all. Finally, 22.5% of characters faced a long-term adverse health consequence, including mental illness, infertility or death. The onscreen abortion mortality rate was 5%, about 7000 times the actual mortality rate.

CONCLUSIONS

Overall, television dramatically exaggerates the risk associated with abortion procedures, overportraying medical complications - particularly major and life-threatening complications - and long-term adverse health consequences. This pattern of misrepresentation may be partially attributable to the occurrence of stories about illegal abortions or abortions taking place outside of modern medical contexts.

IMPLICATIONS

Onscreen abortion portrayals may contribute to inaccurate beliefs about abortion's risk that are common among the public, broadly, and abortion patients, specifically. Abortion advocates and providers will be more equipped to respond misinformation if they understand how and to what extent our popular culture portrays abortion as unsafe.

[Complications of termination of pregnancy]

The legalization of abortion in France allowed to disappear almost maternal deaths caused by induced abortions. Nevertheless, the practice of abortion in a medical framework is encumbered with a number of immediate complications. Similarly, the late consequences of the practice of surgical abortion have generated an abundant literature, which it is important to analyse, both to meet the legitimate concerns of patients as to prevent any spread of false ideas under the influence of movements opposed to abortion.

Risk factors in ectopic pregnancy and differences between adults and adolescents, is consanguinity important?

The aim of the study was to determine the risk factors of ectopic pregnancy (EP) and to compare them between women over and under 20 years of age. 308 cases of EP (case group) were compared with 616 cases of normal pregnancy. Smoking [Ad OR =5.7 (CI 95%=2.8-11.6), p < 0.001], previous EP [Ad OR= 11.4 (CI 95%=3-42.4), p = 0.000], previous STD [Ad OR =3.2 (CI 95%=2.1-4.9), p < 0.001], previous use of IUD [Ad OR =4.1 (CI 95%=2.1-8), p < 0.001], history of infertility [Ad OR= 1.8 (CI 95%=1.1-3), p = 0.01], previous caesarean delivery [Ad OR= 1.5 (CI 95%=1.1-2.3), p = 0.03] and consanguinity [Ad OR =2.2 (CI 95%=1.3-3.6), p = 0.002] were considered as risk factors for EP. Prior abortion [p = 0.000], prior STD [p = 0.004], previous caesarean delivery [p = 0.000] and consanguinity [p = 0.04] were more in the >20-year-old group. Negative Rh [p = 0.02], good economic status [p = 0.000] and prior STD [p = 0.03] were more common in Afghan women. However, previous caesarean delivery [p = 0.04] was more in Iranian women. Smoking, previous EP, history of STD, IUD, infertility, previous caesarean delivery and consanguinity are all risk factors for EP.

Medical Abortion

OBJECTIVE

This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care.

INTENDED USERS

Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services.

TARGET POPULATION

Women with an unintended first trimester pregnancy.

EVIDENCE

Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1).

BENEFITS, HARMS AND/OR COSTS

Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability.

SUMMARY STATEMENTS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care

RECOMMENDATIONS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.

Teen Pregnancy: Are Pregnancies following an Elective Termination Associated with Increased Risk for Adverse Perinatal Outcomes?

STUDY OBJECTIVE

The authors sought to determine whether pregnancies in adolescents following an abortion of pregnancy is associated with an elevated risk for adverse perinatal outcomes.

METHODS

In a cohort study of all adolescent (younger than 18 years) deliveries over a 4-year period at 1 institution, we compared nulliparous women with a history of a prior abortion (cases) to those without a spontaneous loss or abortion of pregnancy (referent) for adverse perinatal outcomes, including preterm birth and fetal growth restriction.

RESULTS

Of the 654 included nulliparous adolescent deliveries, 102 (16%) had an abortion before the index pregnancy. Compared with the referent group, adolescents with a history of a abortion were older (17.8 ± 0.8 vs 16.7 ± 1.2 years, P = .0001), enrolled earlier for prenatal care (14.4 ± 5.6 vs 17.2 ± 7.6 weeks, P = .0004), along with a higher incidence of African American race (95% vs 88%, P = .05). The groups did not differ with respect to other maternal demographics. Perinatal outcomes, including spontaneous preterm birth, abnormal placentation, birth weight, and gestational age at delivery, did not differ between the 2 groups.

CONCLUSION

Compared with adolescent women who had just delivered and did not have a prior abortion, women who had just delivered and had a previous abortion were more likely to be older at the age of their first pregnancy and more likely to initiate early prenatal care. Thus, having a prior abortion may improve the health of a pregnancy though adverse outcomes do not differ between the 2 groups.

Improved Prediction of Preterm Delivery Using Empirical Mode Decomposition Analysis of Uterine Electromyography Signals

Preterm delivery increases the risk of infant mortality and morbidity, and therefore developing reliable methods for predicting its likelihood are of great importance. Previous work using uterine electromyography (EMG) recordings has shown that they may provide a promising and objective way for predicting risk of preterm delivery. However, to date attempts at utilizing computational approaches to achieve sufficient predictive confidence, in terms of area under the curve (AUC) values, have not achieved the high discrimination accuracy that a clinical application requires. In our study, we propose a new analytical approach for assessing the risk of preterm delivery using EMG recordings which firstly employs Empirical Mode Decomposition (EMD) to obtain their Intrinsic Mode Functions (IMF). Next, the entropy values of both instantaneous amplitude and instantaneous frequency of the first ten IMF components are computed in order to derive ratios of these two distinct components as features. Discrimination accuracy of this approach compared to those proposed previously was then calculated using six differently representative classifiers. Finally, three different electrode positions were analyzed for their prediction accuracy of preterm delivery in order to establish which uterine EMG recording location was optimal signal data. Overall, our results show a clear improvement in prediction accuracy of preterm delivery risk compared with previous approaches, achieving an impressive maximum AUC value of 0.986 when using signals from an electrode positioned below the navel. In sum, this provides a promising new method for analyzing uterine EMG signals to permit accurate clinical assessment of preterm delivery risk.

Risk of Adverse Pregnancy Outcomes among Women Practicing Poor Sanitation in Rural India: A Population-Based Prospective Cohort Study

BACKGROUND

The importance of maternal sanitation behaviour during pregnancy for birth outcomes remains unclear. Poor sanitation practices can promote infection and induce stress during pregnancy and may contribute to adverse pregnancy outcomes (APOs). We aimed to assess whether poor sanitation practices were associated with increased risk of APOs such as preterm birth and low birth weight in a population-based study in rural India.

METHODS AND FINDINGS

A prospective cohort of pregnant women (n = 670) in their first trimester of pregnancy was enrolled and followed until birth. Socio-demographic, clinical, and anthropometric factors, along with access to toilets and sanitation practices, were recorded at enrolment (12th week of gestation). A trained community health volunteer conducted home visits to ensure retention in the study and learn about study outcomes during the course of pregnancy. Unadjusted odds ratios (ORs) and adjusted odds ratios (AORs) and 95% confidence intervals for APOs were estimated by logistic regression models. Of the 667 women who were retained at the end of the study, 58.2% practiced open defecation and 25.7% experienced APOs, including 130 (19.4%) preterm births, 95 (14.2%) births with low birth weight, 11 (1.7%) spontaneous abortions, and six (0.9%) stillbirths. Unadjusted ORs for APOs (OR: 2.53; 95% CI: 1.72-3.71), preterm birth (OR: 2.36; 95% CI: 1.54-3.62), and low birth weight (OR: 2.00; 95% CI: 1.24-3.23) were found to be significantly associated with open defecation practices. After adjustment for potential confounders such as maternal socio-demographic and clinical factors, open defecation was still significantly associated with increased odds of APOs (AOR: 2.38; 95% CI: 1.49-3.80) and preterm birth (AOR: 2.22; 95% CI: 1.29-3.79) but not low birth weight (AOR: 1.61; 95% CI: 0.94-2.73). The association between APOs and open defecation was independent of poverty and caste. Even though we accounted for several key confounding factors in our estimates, the possibility of residual confounding should not be ruled out. We did not identify specific exposure pathways that led to the outcomes.

CONCLUSIONS

This study provides the first evidence, to our knowledge, that poor sanitation is associated with a higher risk of APOs. Additional studies are required to elucidate the socio-behavioural and/or biological basis of this association so that appropriate targeted interventions might be designed to support improved birth outcomes in vulnerable populations. While it is intuitive to expect that caste and poverty are associated with poor sanitation practice driving APOs, and we cannot rule out additional confounders, our results demonstrate that the association of poor sanitation practices (open defecation) with these outcomes is independent of poverty. Our results support the need to assess the mechanisms, both biological and behavioural, by which limited access to improved sanitation leads to APOs.

Is It Safe to Provide Abortion Pills over the Counter? A Study on Outcome Following Self-Medication with Abortion Pills

BACKGROUND

Medical abortion is a safe method of termination of pregnancy when performed as per guidelines with a success rate of 92-97 %. But self-administration of abortion pills is rampant throughout the country due to over the counter availability of these drugs and complications are not uncommon due to this practice. The society perceives unsupervised medical abortion as a very safe method of termination and women use this as a method of spacing.

AIM OF THE STUDY

The aim of this study was to study the implications of self-administration of abortion pills by pregnant women.

MATERIALS AND METHODS

Retrospective observational study done in Sri Manakula Vinayagar Medical College & Hospital between the period of July 2013 to June2014. Case sheets were analysed to obtain data regarding self-administration of abortion pills and complications secondary to its administration. The following data were collected. Age, marital status, parity, duration of pregnancy as perceived by the women, confirmation of pregnancy, duration between pill intake and visit to hospital, whether any intervention done elsewhere, any known medical or surgical complications, Hb level on admission, whether patient was in shock, USG findings, evidence of sepsis, blood transfusion, treatment given and duration of hospital stay. Descriptive analysis of the collected data was done.

RESULTS

Among the 128 cases of abortion in the study period, 40 (31.25%) patients had self-administered abortion pills. Among these 40 patients 27.5% had consumed abortion pills after the approved time period of 63 days of which 17.5% had consumed pills after 12 weeks of gestation. The most common presentation was excessive bleeding (77.5%) Severe anaemia was found in 12.5% of the patients and 5% of patients presented with shock. The outcome was as follows : 62.5% of the patients were found to have incomplete abortion, 22.5% had failed abortion and 7.5% of patients had incomplete abortion with sepsis. Surgical evacuation was performed in 67.5% of the patients whereas 12.5% of the patients required surgical evacuation with blood transfusion. Medical methods were used in 15% of the patients whereas 2.5% required transfusion along with medical methods.

CONCLUSION

Unsupervised medical abortion can lead to increased maternal morbidity and mortality. To curtail this harmful practice, strict legislations are required to monitor and also to restrict the sales of abortion pills over the counter and access to abortion pills for the public should be only through centers approved for MTP. Large scale prospective studies are required to assess the actual magnitude of this problem.

[Risk factors associated with spontaneous preterm deliveries before 30 weeks in Martinique F.W.I.: a case-control study]

OBJECTIVES

Early premature delivery is more prevalent in overseas territories than in continental France. Many differences are observed between pregnant women in France and in Martinique which may explain the higher preterm birth rate in the latter territory. The study compares prevalence of possible risk factors in preterm and term deliveries in Martinique.

PATIENTS AND METHODS

A retrospective study was conducted during two years (2010-2011). All deliveries before 30 weeks were included and several characteristics were compared with a group of term deliveries during the same period. All premature deliveries before 30 weeks were collected but only spontaneous ones were analysed.

RESULTS

Fifty deliveries before 30 weeks were recorded, among which 38 were spontaneous. Only a significantly higher prevalence of previous preterm delivery (OR=4.1 [1.3-13]) and twin pregnancies (OR=26.6 [3.19-219.6]) was found in the study group. Gram negative bacterial species were also more prevalent in vaginal sampling of preterm deliveries (OR=23.3 [2.7-204.6]).

CONCLUSION

Factors linked to prematurity before 30 weeks in Martinique are classical. Several features are different between pregnant women in France and in Martinique but do not appear as risk factors for prematurity in the latter territory.

Risk factors for early miscarriage among Chinese: a hospital-based case-control study

OBJECTIVE

To investigate the risk factors for early miscarriage among Chinese women.

DESIGN

Hospital-based matched case-control study.

SETTING

Academic medical center and maternal health hospital.

PATIENT(S)

620 women with early miscarriage (less than 13 weeks of gestation) and 1,240 normal pregnant women.

INTERVENTION(S)

Face-to-face questionnaire.

MAIN OUTCOME MEASURE(S)

Multivariable conditional odds ratio (OR) and 95% confidence interval (CI) to measure risk factors.

RESULT(S)

After adjustment for confounding factors, the following were independently associated with increased risk: history of miscarriage, repeated induced abortion, working night shifts, and frequent staying up late. Vitamin supplementation and regular physical activity reduced the risk of miscarriage. We did not find paternal age, alcohol consumption, or smoking status to be linked with early miscarriage.

CONCLUSION(S)

Our findings suggest that a healthy diet, regular physical activity, and planned pregnancy may be advantageous for women in pre-pregnancy or early pregnancy. Induced abortion, working night shifts, and frequent staying up late were associated with an increased risk of miscarriage. Further work in larger populations is warranted.

Changes in association between previous therapeutic abortion and preterm birth in Scotland, 1980 to 2008: a historical cohort study

BACKGROUND

Numerous studies have demonstrated that therapeutic termination of pregnancy (abortion) is associated with an increased risk of subsequent preterm birth. However, the literature is inconsistent, and methods of abortion have changed dramatically over the last 30 years. We hypothesized that the association between previous abortion and the risk of preterm first birth changed in Scotland between 1 January 1980 and 31 December 2008.

METHODS AND FINDINGS

We studied linked Scottish national databases of births and perinatal deaths. We analysed the risk of preterm birth in relation to the number of previous abortions in 732,719 first births (≥24 wk), adjusting for maternal characteristics. The risk (adjusted odds ratio [95% CI]) of preterm birth was modelled using logistic regression, and associations were expressed for a one-unit increase in the number of previous abortions. Previous abortion was associated with an increased risk of preterm birth (1.12 [1.09-1.16]). When analysed by year of delivery, the association was strongest in 1980-1983 (1.32 [1.21-1.43]), progressively declined between 1984 and 1999, and was no longer apparent in 2000-2003 (0.98 [0.91-1.05]) or 2004-2008 (1.02 [0.95-1.09]). A statistical test for interaction between previous abortion and year was highly statistically significant (p<0.001). Analysis of data for abortions among nulliparous women in Scotland 1992-2008 demonstrated that the proportion that were surgical without use of cervical pre-treatment decreased from 31% to 0.4%, and that the proportion of medical abortions increased from 18% to 68%.

CONCLUSIONS

Previous abortion was a risk factor for spontaneous preterm birth in Scotland in the 1980s and 1990s, but the association progressively weakened and disappeared altogether by 2000. These changes were paralleled by increasing use of medical abortion and cervical pre-treatment prior to surgical abortion. Although it is plausible that the two trends were related, we could not test this directly as the data on the method of prior abortions were not linked to individuals in the cohort. However, we speculate that modernising abortion methods may be an effective long-term strategy to reduce global rates of preterm birth.

Socio-demographic characteristics of women sustaining injuries during pregnancy: a study from the Danish National Birth Cohort

OBJECTIVES

To describe adverse birth outcomes associated with hospital-treated injuries that took place among women in the Danish National Birth Cohort.

DESIGN

Longitudinal cohort study.

SETTING

Denmark.

PARTICIPANTS

90 452 women and their offspring selected from the Danish National Birth Cohort.

PRIMARY AND SECONDARY OUTCOME MEASURES

To determine if injured women were more likely to deliver an infant preterm, with low birth weight, stillborn or have a spontaneous abortion, the authors estimated HRs. ORs were generated to assess APGAR scores and infants born small for gestational age (SGA). Models were adjusted for maternal smoking and drinking during pregnancy, household socioeconomic status, eclampsia/pre-eclampsia or gestational diabetes status during pregnancy and maternal age at birth; estimates for preterm birth were also adjusted for prior history of preterm birth.

RESULTS

In the cohort of 90 452 pregnant women, 3561 (3.9%) received medical treatment for an injury during pregnancy. Injured pregnant women were more likely to deliver infants that were stillborn or have pregnancies terminated by spontaneous abortion. The authors did not detect an adverse effect between injuries sustained during pregnancy and delivery of preterm, low birth weight or SGA infants, or infants with an APGAR score of <7.

CONCLUSIONS

The study shows that injuries occurring among women from an unselected population may not have an adverse effect on birth weight, gestational age, APGAR score or SGA status but may adversely affect the risk of stillbirth and spontaneous abortions in some situations.

Reproductive outcomes following induced abortion: a national register-based cohort study in Scotland

OBJECTIVE

To investigate reproductive outcomes in women following induced abortion (IA).

DESIGN

Retrospective cohort study.

SETTING

Hospital admissions between 1981 and 2007 in Scotland.

PARTICIPANTS

Data were extracted on all women who had an IA, a miscarriage or a live birth from the Scottish Morbidity Records. A total of 120 033, 457 477 and 47 355 women with a documented second pregnancy following an IA, live birth and miscarriage, respectively, were identified.

OUTCOMES

Obstetric and perinatal outcomes, especially preterm delivery in a second ongoing pregnancy following an IA, were compared with those in primigravidae, as well as those who had a miscarriage or live birth in their first pregnancy. Outcomes after surgical and medical termination as well as after one or more consecutive IAs were compared.

RESULTS

IA in a first pregnancy increased the risk of spontaneous preterm birth compared with that in primigravidae (adjusted RR (adj. RR) 1.37, 95% CI 1.32 to 1.42) or women with an initial live birth (adj. RR 1.66, 95% CI 1.58 to 1.74) but not in comparison with women with a previous miscarriage (adj. RR 0.85, 95% CI 0.79 to 0.91). Surgical abortion increased the risk of spontaneous preterm birth compared with medical abortion (adj. RR 1.25, 95% CI 1.07 to 1.45). The adjusted RRs (95% CI) for spontaneous preterm delivery following two, three and four consecutive IAs were 0.94 (0.81 to 1.10), 1.06 (0.76 to 1.47) and 0.92 (0.53 to 1.61), respectively.

CONCLUSIONS

The risk of preterm birth after IA is lower than that after miscarriage but higher than that in a first pregnancy or after a previous live birth. This risk is not increased further in women who undergo two or more consecutive IAs. Surgical abortion appears to be associated with an increased risk of spontaneous preterm birth in comparison with medical termination of pregnancy. Medical termination was not associated with an increased risk of preterm delivery compared to primigravidae.

Mifepristone-induced abortion and vaginal bleeding in subsequent pregnancy

BACKGROUND

The aim of this study is to explore the effect of first-trimester mifepristone-induced abortion on vaginal bleeding in subsequent pregnancy.

STUDY DESIGN

This 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.

RESULTS

The 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.

CONCLUSIONS

One 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.

Obstetric outcome after early placental complications

PURPOSE OF REVIEW

To evaluate the impact of early pregnancy complications involving placentation and early placental development on adverse obstetric outcome in ongoing and subsequent pregnancies.

RECENT FINDINGS

We found an increased risk of adverse outcome (odds ratio >2.0) in ongoing pregnancies of preterm delivery (PTD), very preterm delivery (VPTD), placental abruption, small for gestational age (SGA), low birth weight (LBW) and very LBW (VLBW) after a threatened miscarriage episode; pregnancy-induced hypertension, preeclampsia, placental abruption, PTD, SGA and low 5-min Apgar score following the detection of an intrauterine haematoma; and VPTD, VLBW and perinatal death after a vanishing twin phenomenon. In subsequent pregnancies, the risk of perinatal death was increased (odds ratio >2.0) after a single miscarriage, the risk of VPTD after two or more miscarriages, the risk of placenta previa, premature preterm rupture of membranes, PTD, VPTD and LBW after recurrent miscarriage and the risk of VPTD after two or more terminations of pregnancy.

SUMMARY

Our analysis of the literature review indicates a link between early pregnancy complications involving the placenta and subsequent adverse obstetric and perinatal outcomes. Some of these associations are based on limited or small uncontrolled studies. Larger population-based prospective controlled studies have recently been published confirming most of these findings. This suggests that the early detection of these risk factors could improve the screening of women at high risk of specific obstetric complications in ongoing and subsequent pregnancies.

Health disparities in risk for cervical insufficiency

BACKGROUND

The purpose of the study was to examine racial/ethnic differences in cervical insufficiency risk.

METHODS

We used the US 2005 Natality data file. Analysis was limited to singleton births. The prevalence of cervical insufficiency was examined by the maternal characteristic for each racial group. Unconditional logistic regression modeling was used to assess the association between race and cervical insufficiency while controlling for confounders.

RESULTS

Cervical insufficiency risk for Black women was more than twice that for their White counterparts [odds ratio (OR) (95% confidence interval (CI)) of 2.45 (2.22–2.71)]. Prior pregnancy termination showed a dose–response relationship with cervical insufficiency. Compared with women with no history of prior pregnancy termination, primiparous women who have had one pregnancy termination had an OR (95% CI) of 2.49 (2.23–2.77). The OR for two, three and four or more terminations were 4.66 (4.07–5.33), 8.07 (6.77–9.61) and 12.36 (10.19–15.00), respectively. Other predictors of cervical insufficiency included previous preterm birth, parity, marital status, renal disease, history of diabetes, polyhydramnios and anemia.

CONCLUSIONS

There were significant racial/ethnic disparities with Black women having increased cervical insufficiency risk, independent of other studied factors. Prior pregnancy termination is also a major risk factor for cervical insufficiency. The White/Black disparity is evident in both primiparous and multiparous women.

Mifepristone: pharmacology and clinical impact in reproductive medicine, endocrinology and oncology

IMPORTANCE OF THE FIELD

Mifepristone is a synthetic selective progesterone-receptor modulator (SPRM) that is widely used around the globe in the field of reproductive medicine. At present mifepristone is approved in a number of countries for early termination of pregnancy (TOP), cervical dilatation before surgical TOP, and management of early embryonic loss or fetal death. A number of new clinical applications are being developed in gynecology, endocrinology and oncology. Mifepristone has also served as an invaluable tool in the study of steroid hormone biology.

AREAS COVERED IN THIS REVIEW

Current indications for mifepristone are reviewed. New applications for mifepristone under clinical investigation are discussed. In addition, the unique molecular and cellular effects of mifepristone are described.

WHAT THE READER WILL GAIN

The reader will understand the mechanisms of action of mifepristone and the underlying steroid hormone biology. The reader will know the approved clinical indications for mifepristone and appreciate the ongoing basic and clinical research into new applications.

TAKE HOME MESSAGE

Mifepristone is the first-discovered and still most widely used antiprogestin. It has several indications in reproductive medicine and is under investigation for a variety of potential applications in other fields of medicine. The molecular and cellular effects of mifepristone illuminate important aspects of steroid hormone biology.

Mifepristone-induced abortion and duration of third stage labour in a subsequent pregnancy

To evaluate the impact of mifepristone-induced abortion (MA) on the duration of third stage labour in a subsequent pregnancy, an observational cohort study was conducted from 1998 to 2001 at antenatal clinics in Shanghai, Beijing and Chengdu, China. A total of 4925 pregnant women with no history of induced abortion (NA) and 4931 pregnant women with one previous MA were enrolled and followed until delivery. Of these, 5139 women who delivered singletons vaginally were used in the present analyses, including 2614 with NA and 2525 with a history of MA. Maternal characteristics, labour duration and other obstetric and gynaecological information were obtained. The incidence rates of prolonged third stage of labour were 1.55% and 1.49% in NA and MA, respectively. After adjusting for age at delivery, maternal education, maternal occupation, area of residence, duration of gestational, type of delivery and pregnancy-induced hypertension, MA was not associated with the risk of prolonged third stage of labour (odds ratios = 0.92, 95% confidence interval 0.58, 1.44). Subgroup analysis of women with MA showed similar results regardless of gestational age at abortion, woman's age at abortion, subsequent curettage/complications and the interpregnancy interval. In conclusion, the data did not provide evidence that one MA was associated with the risk of prolonged third stage of labour in a subsequent pregnancy in primiparae.

Is induced abortion a risk factor in subsequent pregnancy?

OBJECTIVE

To determine whether a history of terminations of pregnancy influences subsequent pregnancies in terms of pregnancy risks, prematurity and neonatal biometrics.

PATIENTS AND METHODS

Based on the perinatal statistics of eight German federal states, data of 247,593 primiparous women with singleton pregnancies born between 1998 and 2000 were analyzed. The control group consisted of primiparous women without previous induced abortions. Maternal age was adjusted for.

RESULTS

There was an overall trend towards an increased rate of preterm delivery at <or=36 weeks' gestation and early preterm delivery at <or=31 weeks' gestation in women who had previous pregnancy terminations. For the cohort of 28-30 years, the observed rates of prematurity in women with one and with >or=2 previous induced abortions were 7.8% and 8.5%, respectively, compared to 6.5% in the control population (P=0.015). Preceding terminations of pregnancy did not alter the rate of small-for-gestational-age newborns. Psychosocial stress and symptoms associated with prematurity such as cervical incompetence and vaginal bleeding before and after 28 weeks of gestation occurred more frequently in women with previous induced abortion compared to the control group (P<0.0001).

CONCLUSION

The rate of preterm births increases with the number of preceding abortions. Similarly, symptoms associated with prematurity are more common. The rate of small-for-gestational-age newborns was not affected by preceding terminations of pregnancy.