Abortion patients' decision making about where to obtain out-of-state care following Texas' 2021 abortion ban.

OBJECTIVE: To assess pregnant Texans' decisions about where to obtain out-of-state abortion care following the September 2021 implementation of Senate Bill 8 (SB8), which prohibited abortions after detectable embryonic cardiac activity. DATA SOURCE: In-depth telephone interviews with Texas residents ≥15 years of age who obtained out-of-state abortion care after SB8's implementation. STUDY DESIGN: This qualitative study explored participants' experiences identifying and contacting abortion facilities and their concerns and considerations about traveling out of state. We used inductive and deductive codes in our thematic analysis describing people's decisions about where to obtain care and how they evaluated available options. DATA COLLECTION: Texas residents self-referred to the study from flyers we provided to abortion facilities in Arkansas, Colorado, Kansas, Louisiana, Mississippi, New Mexico, and Oklahoma. We also enrolled participants from a concurrent online survey of Texans seeking abortion care. PRINCIPAL FINDINGS: Participants (n = 65) frequently obtained referral lists for out-of-state locations from health-care providers, and a few received referrals to specific facilities; however, referrals rarely included the information people needed to decide where to obtain care. More than half of the participants prioritized getting the soonest appointment and often contacted multiple locations and traveled further to do so; others who could not travel further typically waited longer for an appointment. Although the participants rarely cited state abortion restrictions or cost of care as their main reason for choosing a location, they often made sacrifices to lessen the logistical and economic hardships that state restrictions and out-of-state travel costs created. Informative abortion facility websites and compassionate scheduling staff solidified some participants' facility choice. CONCLUSIONS: Pregnant Texans made difficult trade-offs and experienced travel-related burdens to obtain out-of-state abortion care. As abortion bans prohibit more people from obtaining in-state care, efforts to strengthen patient navigation are needed to reduce care-seeking burdens as this will support people's reproductive autonomy.

Access to care following Planned Parenthood's termination from Texas' Medicaid network: A qualitative study.

OBJECTIVES: This study aimed to explore Planned Parenthood Medicaid patients' experiences getting reproductive health care in Texas after the state terminated Planned Parenthood providers from its Medicaid program in 2021. STUDY DESIGN: Between January and September 2021, we recruited Medicaid patients who obtained care at Planned Parenthood health centers prior to the state termination using direct mailers, electronic messages, community outreach, and flyers in health centers. We conducted baseline and 2-month follow-up semistructured phone interviews about patients' previous experiences using Medicaid at Planned Parenthood and other providers and how the termination affected their care. We qualitatively analyzed the data using the principles of grounded theory. RESULTS: We interviewed 30 patients, 24 of whom completed follow-up interviews. Participants reported that Planned Parenthood reliably accepted different Medicaid plans, worked with patients to ameliorate the structural barriers they face to care, and referred them to other providers as needed. After Planned Parenthood's termination from the Texas Medicaid program, participants faced difficulties accessing care elsewhere, including same-day appointments and on-site medications. Consequences included delayed or forgone reproductive health care, including contraception, and emotional distress. CONCLUSIONS: Planned Parenthood Medicaid patients found it difficult to connect with other providers for reproductive health care and to obtain evidence-based care following the organization's termination from Medicaid. Ensuring all Medicaid patients have freedom to choose providers would improve access to quality contraception and other reproductive health care. IMPLICATIONS: Medicaid-funded reproductive health care access is restricted for people living on low incomes when providers do not reliably accept all Medicaid plans or cannot participate in Medicaid. This situation can lead to lower quality care, delayed or forgone care, and emotional distress.

New Gaps and Urgent Needs in Graduate Medical Education and Training in Abortion.

Abortion is essential health care, and abortion training and education are essential at all levels of medical education. Among the most common procedures performed in obstetrics and gynecology (OB/GYN), abortion is a core competency for OB/GYN residency programs. For nearly 50 years, the procedure was federally protected by the U.S. Supreme Court's January 22, 1973, Roe v Wade decision. On June 24, 2022, amidst increasing state restrictions limiting abortion access, the Court's decision on Dobbs v Jackson Women's Health Organization effectively reversed Roe . As a result, immediate bans on abortion went into effect across the country, removing access to abortion for millions of people and newly limiting training and education in this core competency for many medical residents. As of June 2022, nearly half of U.S. OB/GYN residency programs and more than 40% of residents are located in states that have banned or are likely to ban abortion. In states where abortion is restricted or illegal, states must adapt quickly to ensure their residents meet training requirements. This adaptation may include developing and leveraging relationships with programs in states where access is protected, depending on simulation, and placing greater emphasis on education and training in pregnancy loss management and postabortion care. None of these is a comprehensive solution and even all together, they are insufficient to train residents and medical students. Ultimately, many future physicians will not receive the training they need to provide full reproductive health care to their pregnant patients. Legal and other systems of support are needed to ensure that current and future physicians can provide compassionate, evidence-based reproductive health care, including essential abortion care.

A Pregnant Patient Presents with Leakage of Vaginal Fluid in the Second Trimester.

Leakage of Vaginal Fluid in the Second TrimesterA pregnant 43-year-old woman presented with leakage of vaginal fluid at 15 weeks of gestation. How do you approach the evaluation, and what is on your differential diagnosis?

Longitudinal outcomes one year following implicit bias training in medical students.

PURPOSE: Training in implicit bias is broadly recognized as important in medical education and is mandated by some accrediting bodies. This study examined medical students' retention of concepts immediately following and one-year post participation in an implicit bias workshop. METHODS: Study subjects were 272 third-year medical students who participated in workshops held between 2018-2020 that used the Implicit Associations Test (IAT) as a trigger for discussions in small groups. We developed a survey and administered it to students to capture their awareness of implicit bias pre-, post-, and one-year post-workshop attendance. Repeated Measures Analyses and independent-samples t-tests were used to examine for differences in responses on each of the seven survey items and a tabulated 7-item average of these seven items. RESULTS: Six of seven survey items and the tabulated 7-item average examined by Repeated Measures Analyses showed statistically significant increases between the pre-, post-, and one-year post-surveys (ps range: 0.01-0.07), with a small to moderate effect sizes (ƞp2s range: 0.01-0.07). Pairwise comparisons among these three surveys' results indicated statistically significant improvements between the pre- and the post-workshop surveys (ps range: 0.01-0.03) but no statistically significant differences between the post- and the one-year post-workshop surveys (ps range: 0.57-0.99). A separate sample of 17 off-cycle students who took the one-year post- workshop survey two years after the workshop did not differ statistically on the level of awareness of bias compared to those taking the same survey one year later, as examined by the two-group independent t-tests for the seven one-year post-workshop survey items (ps range: 0.56-0.99). CONCLUSIONS: The findings support one-year retention of knowledge and attitudes gained from an implicit bias workshop and suggest similar retention at two years. Future educational interventions that train learners to recognize and manage implicit and explicit behaviors in clinical practice are needed.

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).

Association of Immediate Postpartum Etonogestrel Implant Insertion and Venous Thromboembolism.

OBJECTIVE: To estimate the rate of readmissions for postpartum venous thromboembolism (VTE) during the first 30 days postdelivery between women with and without the immediate postpartum insertion of the etonogestrel contraceptive implant. METHODS: The Nationwide Readmissions Database from 2016 was used to identify women with a singleton delivery, immediate postpartum insertion of the etonogestrel contraceptive implant, and readmission for VTE within 30 days of discharge. Those with a prior history of VTE or anticoagulant therapy were excluded. These women were compared with the number of women readmitted within 30 days for VTE who did not have the contraceptive implant placed during delivery admission. RESULTS: Of 3,387,120 deliveries, 8,369 women underwent etonogestrel contraceptive implant placement during the delivery admission. There was no difference identified in the rate of readmission for VTE between exposed and unexposed women. Of these, seven had received a postpartum etonogestrel contraceptive implant (0.85/1,000; 95% CI 0.22-1.45/1,000 deliveries), compared with 1,192 without an etonogestrel contraceptive implant (0.35/1,000; 95% CI 0.33-0.37/1,000 deliveries); odds ratio (OR) 2.41; 95% CI 0.58-9.89. The rates of diabetes, thrombophilia, systemic lupus erythematosus, and cesarean birth did not differ between groups. Women who underwent etonogestrel contraceptive implant placement were younger and were more likely to have government-sponsored health insurance, a smoking history, hypertension, peripartum infection, or postpartum hemorrhage than women who did not receive an etonogestrel contraceptive implant (P<.001). After adjusting for these confounders, there remained no difference in rates of VTE, adjusted OR 1.81; 95% CI 0.44-7.45. CONCLUSION: The immediate postpartum placement of the etonogestrel contraceptive implant was not associated with an increased rate of VTE; however, our sample size was underpowered to determine no difference.

Abortion in adolescents: epidemiology, confidentiality, and methods.

PURPOSE OF REVIEW: To review the epidemiology, confidentiality, and methods of abortion provision specific to adolescents. RECENT FINDINGS: In the United States, four out of five pregnancies in teenagers are unintended and about one-third of all adolescent pregnancies end in induced abortion. Barriers such as travel and cost decrease abortion access for all women and adolescents, whose pregnancies are diagnosed later than older women, may be particularly impacted by such challenges. An increasing majority of states require parental involvement in adolescents' decisions to end their pregnancies. Recent analyses indicate that mandating parental involvement does not promote family communication; rather, such laws may actually increase the risk of harm by delaying appropriate medical care. Medication and surgical abortion are options for adolescents; both are safe and effective. There is no evidence that abortion during adolescence causes negative psychological consequences, decreased fertility, or increased risk in future pregnancies. SUMMARY: Continued high rates of unintended pregnancy among US adolescents necessitate access to safe and timely abortion services. Unfortunately, teens encounter unique barriers in obtaining abortion care that lead to delays and preventable risk associated with later abortion.

Balloon tamponade of hemorrhage after uterine curettage for gestational trophoblastic disease.

BACKGROUND: Uterine bleeding frequently complicates gestational trophoblastic disease, particularly after uterine evacuation. Hysterectomy and other procedures used to control this bleeding incur significant risk and can limit fertility. CASE: We present a case of massive hemorrhage complicating uterine curettage performed for metastatic gestational trophoblastic disease. The patient's bleeding was controlled successfully by intrauterine tamponade performed using a balloon catheter. After catheter removal, she achieved complete disease remission. CONCLUSION: Intrauterine balloon catheterization appears to be a promising alternative to control uterine hemorrhage and preserve fertility for young women undergoing treatment for gestational trophoblastic disease. Its use may help avoid invasive interventions, such as hysterectomy and embolization, currently used to control hemorrhage after uterine evacuation.