Intrauterine Device Placement Success for Adolescents and Young Adults at Community-Based Reproductive Health Clinics.

BACKGROUND: Despite the endorsement of intrauterine device (IUD) use in adolescents and young adults (AYAs) by leading professional organizations and demonstrated acceptance and desirability by AYAs, clinicians may worry about the procedural difficulty of IUD device placement in younger patients. OBJECTIVE: The aim of this study was to evaluate the clinical outcomes of first-attempt IUD placement in an AYA population by vaginal delivery (VD) history. STUDY DESIGN: We performed a retrospective cohort study of patients under 25 years old at reproductive health clinics with an IUD placement attempt between January 1 and August 31, 2017. We abstracted sociodemographic characteristics, pregnancy history, and procedural characteristics including complications. Bivariate analyses compared successful first-attempt IUD placement by VD history. We also assessed the frequency of secondary clinical outcomes including ancillary measures used, provider type, symptoms reported during the procedure, and complications. RESULTS: We included 1325 participants (median age = 21.3 years), including 42 (3.2%) with a previous VD. Nearly all IUD placements were successful on the first attempt (n = 1301, 98.2%) and performed by advanced practice clinicians (n = 1314, 99.2%). First-attempt IUD placement success was similar in those participants with and without VD (P > .999). Ancillary measures other than nonsteroidal anti-inflammatory drugs were used infrequently (n = 16, 3.6%). Among participants with an unsuccessful placement, 66.7% returned, and all had a successful IUD placement on the second attempt. Documented complications within 6 months of placement were rare (n = 29) and mostly comprised expulsions (n = 27, 93.1%). CONCLUSION: IUD placement success among AYAs at community-based reproductive health clinics is high and is not associated with a history of VD.

Evaluation of a "smart" screening tool for asynchronous assessment of medication abortion eligibility: A pilot study.

OBJECTIVES: This study aimed to assess the feasibility, safety, and acceptability of asynchronous screening for medication abortion eligibility using a programmed questionnaire. STUDY DESIGN: For this study, we developed an informational website about medication abortion with a linked questionnaire programmed to produce a conclusion regarding eligibility according to standard criteria. We enrolled people in Colorado and Minnesota who submitted questionnaires indicating eligibility. A study physician reviewed each questionnaire and medical records if available and determined whether the responses warranted treatment without a synchronous clinical consultation or ultrasound. If so, the physician prescribed a standard regimen of mifepristone and misoprostol. We collected posttreatment data on abortion outcome, adverse events, and satisfaction. RESULTS: We received questionnaires from 197 individuals, of whom 160 remained in the study until the physician made a final treatment decision. Physicians prescribed medication abortion to 156 (97.5%) individuals based on the questionnaire responses, whereas four needed further assessment to confirm eligibility. Of the 156 individuals, 130 had sufficient follow-up to assess abortion outcome, and 123 (95%) had complete medication abortions without additional treatment. One participant was hospitalized for bleeding, and one expelled a 15-week fetus; however, it is not clear that conventional synchronous history-based screening would have averted these events. Of the 197 questionnaires, 42% were submitted outside business hours. On satisfaction questionnaires, 134 (96%) of 144 participants said they would recommend the study to a friend who needed an abortion. CONCLUSIONS: Data from this pilot project suggest that providing medication abortion based only on a self-administered, programmed questionnaire is likely to be effective, safe, efficient, and acceptable. IMPLICATIONS: A programmed self-administered patient questionnaire to assess eligibility for medication abortion could reduce the cost of the service, augment clinic efficiency, improve quality of care, and enhance access to abortion.

Willingness to use novel reversible methods of male birth control: a community-based survey of cisgender men in the United States.

BACKGROUND: There is high global demand for new methods of male birth control (MBC). However, contemporary evidence regarding men's method-specific attitudes and their determinants is sparse. METHODS: Non-sterilized cisgender men ages 18-45 with recent history of female sex partners were surveyed at a large community event in the Midwestern US. We examined variation in participants' willingness to use MBC by method (gel, pill, injection, implant, and vas occlusion), potential side effects, and potential barriers. We estimated crude and adjusted prevalence ratios (aPRs) for associations between participant characteristics and willingness to use ≥ 1 MBC method. RESULTS: Overall, 72% of participants (n = 187; mean age, 29) were very willing to use ≥ 1 MBC method although support for individual methods ranged widely from 62% (pill) to 24% (vas occlusion). In bivariate analysis of sociodemographic and health characteristics, few demonstrated associations with MBC willingness. In a multivariable model, willingness was independently related to age (30-39 vs. 18-29 years old, aPR = 1.24, 95% CI 1.04-1.48) and having ever been tested for HIV (aPR = 1.27, 95% CI 1.07-1.51). Willingness to tolerate side effects was < 10% for most items. The most commonly endorsed barriers to MBC use were high cost (77%) and side effects (66%). CONCLUSIONS: Enthusiasm for MBC was high but waned in the context of potential side effects and barriers. Additional research on MBC attitudes in socioeconomically and culturally diverse populations worldwide is sorely needed.

Mailing abortion pills does not delay care: A cohort study comparing mailed to in-person dispensing of abortion medications in the United States.

OBJECTIVE: Given the substantial barriers to abortion access in the United States, many clinics now mail patients abortion medications. We examined whether dispensing the medications by mail prolonged time to medication use. STUDY DESIGN: We analyzed data from no-test medication abortions with medication provided either by mail or in a clinic from 11 United States clinics from February 2020 to January 2021. We examined mean number of days from patients' first contact with the clinic to mifepristone ingestion, its two-component intervals (first contact to medication dispensing and dispensing to mifepristone ingestion), and pregnancy duration at mifepristone ingestion. We used Poisson regression to compare mean outcomes across three dispensing methods: in-person, mailed from the clinic, and mailed from a mail-order pharmacy. RESULTS: Among the 2600 records, patients took mifepristone on average at 49 days of gestation (95% CI, 47-51) and 7 days (95% CI, 4-10) after first contact. Mean time from first contact to mifepristone ingestion was 6 days when medications were dispensed in-person and 9 days when mailed (p = 0.38). While time from first contact to dispensing was similar across methods (6 days in-person, 5 days mailed, p = 0.77), more time elapsed from dispensing to mifepristone ingestion when medications were mailed (4 days from clinic, 5 days from mail-order pharmacy) versus dispensed in-person (0.3 days, p < 0.001). Time to mifepristone ingestion was shorter with higher pregnancy duration. Pregnancy duration at ingestion was similar across methods (48 days in-person, 50 days mailed). CONCLUSIONS: Mailing medications did not significantly prolong time from patients' first contact with the clinic to mifepristone ingestion or increase pregnancy duration at mifepristone ingestion. IMPLICATIONS: Abortion providers should offer a range of medication abortion dispensing options, prioritizing patient preference.

Medication abortion and uterine aspiration for undesired pregnancy of unknown location: A retrospective cohort study.

OBJECTIVE: To compare days to diagnosis of pregnancy location for same-day medication abortion and same-day uterine aspiration with delayed treatment (expectant management) in patients with undesired pregnancy of unknown location (PUL). STUDY DESIGN: We conducted a retrospective cohort study at a single Planned Parenthood health center in Minnesota. We reviewed electronic health records and included patients presenting for induced abortion diagnosed with PUL (positive high-sensitivity urine pregnancy test and no evidence of intrauterine or extrauterine pregnancy on transvaginal ultrasonography) without symptoms or ultrasonographic imaging concerning for ectopic pregnancy (low risk). The primary outcome was days to pregnancy location clinical diagnosis. RESULTS: Of 19,151 abortion encounters in 2016-2019, 501 (2.6%) had a low-risk PUL. Participants chose delay-for-diagnosis before treatment (148, 29.5%), immediate treatment medication abortion (244, 48.7%), or immediate treatment uterine aspiration (109, 21.8%). Median days to diagnosis were significantly lower in the immediate treatment uterine aspiration group (2 days, IQR 1-3 days, p < 0.001) and similar for immediate treatment medication abortion (4 days, IQR 3-9 days, p = 0.304) compared with delay-for-diagnosis (3 days, IQR 2-10 days). Thirty-three low-risk participants (6.6%) were treated for ectopic pregnancy, but no difference in ectopic rate was detected among groups (p = 0.725). Participants in the delay-for-diagnosis group were more likely to be nonadherent with follow-up (p < 0.001). For participants who completed follow-up, abortion completion rate was lower for immediate treatment medication abortion (85.2%) compared with immediate treatment uterine aspiration (97.6%, p = 0.003). CONCLUSIONS: For patients with undesired PUL, diagnosis of pregnancy location was fastest with immediate treatment uterine aspiration and similar for expectant management and immediate treatment medication abortion. Medication abortion efficacy may be reduced in treatment of undesired PUL. IMPLICATIONS: For PUL patients desiring induced abortion, the option of proceeding at initial encounter may help improve access and patient satisfaction. Uterine aspiration for PUL may help diagnose pregnancy location more quickly.

Evaluation of Strategies to Improve Uptake of Expedited Partner Therapy for Chlamydia trachomatis Treatment in Minnesota: A Decision Analytic Model.

Background. Despite the established effectiveness of expedited partner therapy (EPT) in partner treatment of bacterial sexually transmitted infections (STI), the practice is underutilized. Objective. To estimate the relative effectiveness of strategies to increase EPT uptake (numbers of partners treated for chlamydia). Methods. We developed a care cascade model of cumulative probabilities to estimate the number of partners treated under strategies to increase EPT uptake in Minnesota. The care cascade model used data from clinical trials, population-based studies, and Minnesota chlamydia surveillance as well as in-depth interviews of health providers who regularly treat STI patients and a statewide survey of health providers across Minnesota. Results. Several strategies could improve EPT uptake among providers, including facilitating treatment payment (additional 1,932 partners treated) and implementing electronic health record reminders (additional 1,755 partners treated). Addressing concerns about liability would have the greatest effect, resulting in 2,187 additional partners treated. Conclusions. Providers expressed openness to offering EPT under several scenarios, which reflect differences in knowledge about EPT, its legality, and potential risks to patients. While addressing concerns about provider liability would have the greatest effect on number of partners treated, provider education and procedural changes could make a substantial impact. Highlights: Addressing provider concerns about expedited partner therapy (EPT) legality and its potential risks would result in the most partners treated for chlamydia.EPT alerts and electronic EPT prescriptions may also streamline partner treatment.Provider education about the legality of EPT and its potential risks and training in counseling patients on EPT could also increase uptake.

More than tears: associations between exposure to chemical agents used by law enforcement and adverse reproductive health outcomes.

Despite routine law enforcement use of chemical agents for crowd control, the reproductive health safety profiles of these products are unknown. Moreover, limited evidence has documented a link between such exposures and adverse reproductive health outcomes including abnormal uterine bleeding and potential pregnancy disruption. This cross-sectional study examined reproductive outcomes in adults with uteri exposed to chemical agents used by law enforcement, more commonly known as "tear gas". Participants were recruited through social media in the wake of police violence protests. Of the 1,276 participants included in analysis, 83% reported experiencing at least one of the outcomes of interest, included uterine cramping (69%), early menstrual bleeding (55%), breast tenderness (30%), and delayed menstrual bleeding (19%). Chemical agent exposure was significantly associated with higher odds of an adverse reproductive health outcome, those with 5 days or more of exposure have 2.6 times the odds (CI: 1.61, 4.22) of adverse outcomes and having a perception that one's menstruation may fluctuate according to psychosocial stressors was associated (OR = 1.94, CI: 1.36, 2.79) with a higher odds of an adverse reproductive health experience. These findings suggest a potential relationship between exposure to chemical agents and adverse reproductive health outcomes. Given the pervasive use of these chemical agents and their potential for reproductive health harm, further investigation into the safety of these products and their impacts on individual and community health is warranted urgently.

Associations Between Income Status and Perceived Barriers to Using Long-Acting Reversible Contraception: An Exploratory Study.

Introduction: Barriers to long-acting reversible contraception (LARC) use in the United States have been described in prior studies, but few have focused on women's income status. We explored associations between income status and perceived LARC barriers in a community-based sample of reproductive-aged women. Methods: Non-pregnant, heterosexually active women aged 18 to 40 years completed a cross-sectional survey at a large community event in the Midwestern U.S. in 2018. Outcome measures were comprised of 26 survey items gauging perceived barriers to LARC use (e.g., access barriers, side effects). We estimated crude and age-adjusted prevalence ratios (PRs) for each outcome by participants' income status: low-income (≤ 200% of federal poverty guideline) versus higher income. Results: Low-income women (n = 72) were significantly more likely than higher income women (n = 183) to endorse 11 of the 26 barriers to LARC use (PR range, 1.23-7.63). Cost of LARC was the most frequently identified access barrier and was more acute for low-income women (PR 1.57, 95% CI 1.17-2.11). After adjustment for age, most associations were attenuated. However, low-income women were still more likely to report concerns about LARC use due to family expectations or beliefs (aPR 3.69, 95% CI 1.15-11.8). Conclusion: Low-income women perceive more barriers to LARC access and more negative perceptions about use. While these associations also correlate with age, they nonetheless reflect concerns that impact contraceptive equity. Efforts to increase LARC access should address these barriers and focus on concerns more common among low-income women regarding LARC use.

A Statewide Mixed-Methods Study of Provider Knowledge and Behavior Administering Expedited Partner Therapy for Chlamydia and Gonorrhea.

BACKGROUND: Expedited partner therapy (EPT) refers to the practice of having patients diagnosed with chlamydia or gonorrhea deliver medication directly to their partner(s) to treat them presumptively for infection. Although EPT facilitates timely treatment and prevents reinfection, it remains underused. We used findings from key informant interviews to design and implement a statewide survey to estimate knowledge and utilization of EPT and to identify barriers and facilitators to EPT among Minnesota providers. METHODS: From November to December 2020, we carried out 15 interviews with health providers who currently provide EPT and coded interviews by recurring themes. We then conducted a statewide online survey on sexually transmitted infection treatment and barriers to EPT, from December 2020 to March 2021. We disseminated the survey to all licensed Minnesota health providers, and those who reported treating bacterial sexually transmitted infections in the past year were included in the study. RESULTS: Interview themes included the importance of direct provision of partner medication, administrative/pharmacy barriers to treatment, inclusive EPT eligibility, and patient counseling. Of the 623 health providers who completed the online survey, only 70% thought EPT was legal and only 37% currently offer EPT. Of those who did not provide EPT, 78% said they would under certain circumstances. Barriers included concerns about safety/liability of prescribing without a medical examination, administrative concerns about prescriptions, and patient acceptance. CONCLUSIONS: Given that over a quarter of respondents did not know expedited partner therapy (EPT)'s legal status, improving provider education may increase EPT provision. More research is needed on system-level barriers and patient acceptance of solutions identified in this study.

PrEP-aring the General Gynecologist to Offer HIV Pre-exposure Prophylaxis.

It is estimated that 450,000 American women are at increased risk of infection with human immunodeficiency virus (HIV), and yet only 7% have a prescription for pre-exposure prophylaxis (PrEP). PrEP is a safe and effective method of HIV infection prevention via a daily use of an oral combination antiretroviral pill or longer-acting intramuscular injections. Gynecologists are experts in women's sexual health, and provide over half of annual preventative health visits, but are not yet routinely providing PrEP to patients, citing lack of knowledge as a major barrier. The authors aim to provide the general gynecologist with the skills to expertly provide PrEP to their patients to reduce HIV infection.

Outcomes and Safety of History-Based Screening for Medication Abortion: A Retrospective Multicenter Cohort Study.

Importance: Screening for medication abortion eligibility typically includes ultrasonography or pelvic examination. To reduce physical contact during the COVID-19 pandemic, many clinicians stopped requiring tests before medication abortion and instead screened patients for pregnancy duration and ectopic pregnancy risk by history alone. However, few US-based studies have been conducted on the outcomes and safety of this novel model of care. Objective: To evaluate the outcomes and safety of a history-based screening, no-test approach to medication abortion care. Design, Setting, and Participants: This retrospective cohort study included patients obtaining a medication abortion without preabortion ultrasonography or pelvic examination between February 1, 2020, and January 31, 2021, at 14 independent, Planned Parenthood, academic-affiliated, and online-only clinics throughout the US. Exposures: Medications for abortion provided without preabortion ultrasonography or pelvic examination and dispensed to patients in person or by mail. Main Outcomes and Measures: Effectiveness, defined as complete abortion after 200 µg of mifepristone and up to 1600 µg of misoprostol without additional intervention, and major abortion-related adverse events, defined as hospital admission, major surgery, or blood transfusion. Results: The study included data on 3779 patients with eligible abortions. The study participants were racially and ethnically diverse and included 870 (23.0%) Black patients, 533 (14.1%) Latinx/Hispanic patients, 1623 (42.9%) White patients, and 327 (8.7%) who identified as multiracial or with other racial or ethnic groups. For most (2626 [69.5%]), it was their first medication abortion. Patients lived in 34 states, and 2785 (73.7%) lived in urban areas. In 2511 (66.4%) abortions, the medications were dispensed in person; in the other 1268 (33.6%), they were mailed to the patient. Follow-up data were obtained for 2825 abortions (74.8%), and multiple imputation was used to account for missing data. Across the sample, 12 abortions (0.54%; 95% CI, 0.18%-0.90%) were followed by major abortion-related adverse events, and 4 patients (0.22%; 95% CI, 0.00%-0.45%) were treated for ectopic pregnancies. Follow-up identified 9 (0.40%; 95% CI, 0.00%-0.84%) patients who had pregnancy durations of greater than 70 days on the date the mifepristone was dispensed that were not identified at screening. The adjusted effectiveness rate was 94.8% (95% CI, 93.6%-95.9%). Effectiveness was similar when medications were dispensed in person (95.4%; 95% CI, 94.1%-96.7%) or mailed (93.3%; 95% CI, 90.7%-95.9%). Conclusions and Relevance: In this cohort study, screening for medication abortion eligibility by history alone was effective and safe with either in-person dispensing or mailing of medications, resulting in outcomes similar to published rates of models involving ultrasonography or pelvic examination. This approach may facilitate more equitable access to this essential service by increasing the types of clinicians and locations offering abortion care.

Clinical and service delivery implications of omitting ultrasound before medication abortion provided via direct-to-patient telemedicine and mail in the U.S.

OBJECTIVES: To compare outcomes among patients who did or did not have pre-abortion ultrasound or pelvic exam before obtaining medication abortion (MA) via direct-to-patient telemedicine and mail. STUDY DESIGN: We analyzed data from participants screened for enrollment into the TelAbortion study at five sites from March 25 to September 15, 2020. We compared participants who had preabortion ultrasound or pelvic exam ("test-MA") to those who did not ("no-test MA"). Outcomes were: abortion not complete with pills alone (i.e., had procedure intervention or ongoing pregnancy), ongoing pregnancy separately, ectopic pregnancy, hospitalization and/or blood transfusion, and unplanned clinical encounters. We used propensity score weighting and multivariable logistic regression to adjust for baseline characteristics. RESULTS: Our analysis included 287 participants who had no-test MA and 125 who had test-MA. Abortion was not complete with pills alone in 16of 287 (5.6%) no-test MA patients compared to 2of 123 (1.9%) test-MA patients (adjusted risk difference [aRD] = 4.3%, 95% confidence interval [CI]: 1.4%-7.1%). No ectopic pregnancies were detected. Groups did not differ regarding hospitalization and/or blood transfusion (p = 0.76) or ongoing pregnancy diagnosis (p = 0.59). Unplanned clinical encounters were more common in no-test MA patients (35of 287, 12.5%) than test-MA patients (10of 125, 8.0%, aRD = 6.7%, 95% CI: 0.5%-13.1%). CONCLUSIONS: Compared to patients who had pre-abortion ultrasound, patients who had no-test MA via telemedicine were more likely to have abortions that were not complete with pills alone and/or unplanned clinical encounters. However, both no-test and test-MA patients had similar and very low rates of ongoing pregnancy and hospitalization or blood transfusion. IMPLICATIONS: Omitting pre-abortion ultrasound before provision of medication abortion via telemedicine does not appear to compromise safety or result in more ongoing pregnancies. However, compared to patients who have preabortion ultrasound, patients who do not have pre-abortion tests may be more likely to seek post-treatment care and have procedural interventions.

Expansion of a direct-to-patient telemedicine abortion service in the United States and experience during the COVID-19 pandemic.

OBJECTIVE: To present updated evidence on the safety, efficacy and acceptability of a direct-to-patient telemedicine abortion service and describe how the service functioned during the COVID-19 pandemic. STUDY DESIGN: We offered the study at 10 sites that provided the service in 13 states and Washington DC. Interested individuals obtained any needed preabortion tests locally and had a videoconference with a study clinician. Sites sent study packages containing mifepristone and misoprostol by mail and had remote follow-up consultations within one month by telephone (or by online survey, if the participant could not be reached) to evaluate abortion completeness. The analysis was descriptive. RESULTS: We mailed 1390 packages between May 2016 and September 2020. Of the 83% (1157/1390) of abortions for which we obtained outcome information, 95% (1103/1157) were completed without a procedure. Participants made 70 unplanned visits to emergency rooms or urgent care centers for reasons related to the abortion (6%), and 10 serious adverse events occurred, including 5 transfusions (0.4%). Enrollment increased substantially with the onset of COVID-19. Although a screening ultrasound was required, sites determined in 52% (346/669) of abortions that occurred during COVID that those participants should not get the test to protect their health. Use of urine pregnancy test to confirm abortion completion increased from 67% (144/214) in the 6 months prior to COVID to 90% (602/669) in the 6 months during COVID. Nearly all satisfaction questionnaires (99%, 1013/1022) recorded that participants were satisfied with the service. CONCLUSIONS: This direct-to-patient telemedicine service was safe, effective, and acceptable, and supports the claim that there is no medical reason for mifepristone to be dispensed in clinics as required by the Food and Drug Administration. In some cases, participants did not need to visit any facilities to obtain the service, which was critical to protecting patient safety during the COVID-19 pandemic. IMPLICATIONS: Medical abortion using telemedicine and mail is effective and can be safely provided without a pretreatment ultrasound. This method of service delivery has the potential to greatly improve access to abortion care in the United States.

"False positive" urine pregnancy test results after successful medication abortion.

OBJECTIVE: To examine the proportion of high-sensitivity urine pregnancy test (HSPT) results that were positive by time after successful medication abortion. STUDY DESIGN: We used data from an ongoing study that provides mifepristone and misoprostol for medication abortion by direct-to-patient telemedicine and mail. Providers evaluated abortion outcomes by patient interview and clinical tests per clinical judgment and participant preference. We identified all participants enrolled July 2016 to September, 2020 who had an HSPT result and no indication of viable pregnancy after treatment. We used logistic regression to examine the association between the timing of the initial post-treatment HSPT, gestational age, and the proportion of HSPTs that gave a positive result. RESULTS: Of the 472 participants in our analysis, 88 (19%) had positive initial HSPTs. The proportions that were positive at ≤20 days, 21 to 27 days, 28 to 34 days, and ≥35 days after mifepristone ingestion was 14 of 29 (48%), 15 of 58 (26%), 49 of 258 (19%), and 10 of 127 (8%), respectively (p < 0.001). Gestational age at mifepristone ingestion was not significantly related to positive HSPT results (p = 0.28). Multivariable logistic regression confirmed both findings and did not identify a statistically significant interaction between these variables. In the 67 participants who relied solely on further HSPTs to confirm abortion outcome, the median interval between the initial positive test and first negative test was 14 days. CONCLUSIONS: The proportion of participants with positive HSPTs declined with time after successful medication abortion. However, nearly one-fifth of participants with complete abortion had positive tests 4 weeks after treatment. IMPLICATIONS: HSPTs provide an inexpensive, convenient option for confirming success of medication abortion at home. However, a substantial minority of patients without ongoing pregnancy have positive HSPT results. Development of a symptom-based strategy for medication abortion outcome assessment without any confirmatory tests should be a priority.

Maternal and neonatal outcomes among incarcerated women who gave birth in custody.

BACKGROUND: In the United States, the population of incarcerated women has increased by more than 600% since the 1980s. With this rise, correctional facilities have faced new challenges meeting the health care needs of women, especially those who are pregnant. This retrospective cohort study sought to describe five indicators of maternal and neonatal health among women who gave birth in custody, and to compare outcomes among incarcerated women who did and did not receive enhanced pregnancy support. METHODS: We used deidentified electronic health records (EHRs) to examine maternal and neonatal birth outcomes (ie, mode of birth, low birthweight, preterm birth, APGAR score, NICU admission) among women who gave birth in custody. Regression models examined differences in outcomes between women who received enhanced pregnancy support-group prenatal education and one-on-one doula visits-and a historical control group of women who received standard prenatal care. RESULTS: Adverse maternal and neonatal birth outcomes in this sample were rare. No differences in outcomes were found between incarcerated women who received enhanced pregnancy support and the historical control group. CONCLUSIONS: Despite evidence for the benefits of enhanced pregnancy support in the general population, this study did not find differences in outcomes between incarcerated women who did and did not receive support. Integrated data from prison and hospital records are innovative, but effect measurement is limited by sample size. Future research should include primary data collection on maternal, neonatal, and dyadic outcomes longitudinally and across prisons.

Copper intrauterine device placement 6-14 days after unprotected sex.

OBJECTIVE: To evaluate pregnancy risk following copper (CuT380A) intrauterine device (IUD) placement 6-14 days after unprotected intercourse. STUDY DESIGN: We used a combined dataset from four protocols in which participants had received a CuT380A IUD regardless of recent unprotected intercourse. At entry, participants had negative point of care urine pregnancy testing and reported all acts of unprotected intercourse in the two weeks prior to IUD placement. We identified a subset of women who had placement 6-14 days after unprotected intercourse and provided follow-up information on pregnancy status 2-4 weeks after IUD insertion. This follow-up within the four protocols included self -administered home urine pregnancy test (UPT) results 2-4 weeks after IUD placement or continued contact for up to 6 months. RESULTS: We identified 134 women who had a CuT380A IUD placed 6-14 days after unprotected intercourse and provided follow-up information on pregnancy status. Ninety-five (71%) participants reported UPT results 2-4 weeks after placement and the other 39 women were followed for 6 months after IUD placement to assess pregnancy status. Zero (97.5% CI 0-2.7%) participants reported a pregnancy within four weeks of CuT380A IUD placement. CONCLUSION: In these collected data, no women with recent unprotected intercourse became pregnant within 1 month of CuT380A IUD placement. IMPLICATION: These data indicate a low likelihood of pregnancy among women who reported unprotected intercourse 6-14 days preceding IUD insertion. For many women and their providers, these data may be sufficient to support same-day placement of a copper IUD rather than delaying IUD placement until the next menses.

Simplified medical abortion screening: a demonstration project.

OBJECTIVES: The objectives were to evaluate the safety and acceptability of outpatient medical abortion in selected women without a pretreatment ultrasound or pelvic examination. STUDY DESIGN: We conducted a prospective case-series study to estimate the incidence of serious adverse events (death, life-threatening event, hospitalization, transfusion or any other medical problem that we judged to be significant), surgical completion of the abortion and satisfaction in women provided with medical abortion without a pretreatment ultrasound or pelvic examination. We enrolled 406 women requesting medical abortion in Moldova, Mexico and the United States. To be eligible, a woman must have been certain that her last menstrual period started within the prior 56days, have had regular menses before the pregnancy, not have used hormonal contraceptives in the prior 2months (in the United States and Mexico) or 3months (in Moldova), have no risk factors for or symptoms of ectopic pregnancy, and not have had an ultrasound or pelvic exam in this pregnancy. One site also excluded women with uterine enlargement on abdominal palpation. Each participant received mifepristone (200mg orally) and misoprostol (400 mcg sublingually in Moldova; 800 mcg buccally at all other sites) and was followed until complete abortion, defined as requiring no further treatment. RESULTS: Of the 365 (90%) participants who provided sufficient follow-up information for analysis, 347 (95%) had complete abortion without additional treatment, 5 (1%) had surgical aspiration, and 10 (3%) had extra misoprostol. Three participants (1%) had serious adverse events; these included two hospital admissions for heavy bleeding managed with aspiration and one diagnosis of persistent gestational sac 19days after enrollment. Most (317, 90%) participants were pleased with omitting the pretreatment ultrasound and pelvic exam. CONCLUSIONS: In this study, medical abortion without screening ultrasound or pelvic exam resulted in no serious adverse events that were likely to have been prevented by those tests and was highly acceptable. IMPLICATIONS: Screening for medical abortion without exam or ultrasound shows promise as a means for increasing access to this service. More research is needed to develop screening criteria that are more inclusive and simpler for clinical use.

Use of an endotracheal tube for surgical abortion complicated by a leiomyomatous uterus: a case report.

BACKGROUND: Abnormal uterine anatomy, especially leiomyomas, can significantly impact the difficulty and potential morbidity of surgical uterine evacuation. To avoid hysterotomy and/or hysterectomy, limited evidence exists to guide surgical uterine evacuation when pregnancy tissue is inaccessible with routine instruments. CASE PRESENTATION: A 41-year-old G4P1021 African American woman at 14 4/7 weeks' gestation was referred for surgical-induced abortion in the setting of an enlarged leiomyomatous uterus. Two large opposing leiomyomas at the internal cervical os rendered pregnancy tissue inaccessible with routine gynecologic surgical instruments. With ultrasound guidance, an endotracheal tube was connected to routine electric suction and utilized to complete uterine evacuation. CONCLUSIONS: With distorted or markedly enlarged uterine anatomy rendering pregnancy tissue inaccessible with routine surgical instruments, the minimally invasive use of an endotracheal tube may aid completion of uterine evacuation for surgical uterine evacuation.