Prospective quantification of fetomaternal hemorrhage with dilation and evacuation procedures.

OBJECTIVE: To describe fetomaternal hemorrhage (FMH) during second-trimester dilation and evacuation (D&E) to evaluate if Rhesus-immune globulin (RhIG) 100 mcg (used in the United Kingdom) and 300 mcg (used in the United States) provide adequate prophylaxis. STUDY DESIGN: We conducted an exploratory prospective descriptive study of women undergoing D&E between 15 weeks 0 days and 23 weeks 6 days of gestation. Enrolled participants had Kleihauer-Betke testing on specimens obtained before and after D&E. We assessed the main outcome measures of FMH in mL suggesting need for more than 100 mcg and 300 mcg RhIG (FMH of 10 mL and 30 mL fetal whole blood, respectively) and association of postprocedure FMH with demographic characteristics and procedure-related variables. RESULTS: The 300 participants had a mean gestational age of 19 weeks 6 days±2 weeks 2 days. The median preprocedure FMH was 0 mL (range 0-50 mL) with 2 (0.67%) women exceeding 10 mL (19 mL and 50 mL). The median postprocedure FMH was 1 mL (range 0-60 mL). Almost all participants had postprocedure FMH <10 mL (n=295, 98.3%) and <30 mL (n=298, 99.3%). All participants under 18 weeks had FMH <10 mL. We found no demographic or procedure-related factors to be predictive of FMH quantity. CONCLUSIONS: FMH occurring with routine second-trimester D&E procedures is minimal. Adequate prophylaxis with RhIG 100 mcg and 300 mcg occurred in >98% of women and in all cases <18 weeks of gestation. This study is the first step to potentially reducing the dose and costs of RhIG administration with D&E. IMPLICATIONS: This study is a first step in quantifying fetomaternal hemorrhage with routine dilation and evacuation procedures; larger trials are needed, especially to understand why some women have recognizable hemorrhage preprocedure. If dosing requirements are too high with current guidelines, lower doses will result in resource and cost savings.

Long-Acting Reversible Contraception Initiation With a 2- to 3-Week Compared With a 6-Week Postpartum Visit.

OBJECTIVE: To evaluate whether a department policy changing the scheduling of the postpartum visit from 6 weeks to 2-3 weeks after delivery is associated with higher long-acting reversible contraception initiation at the postpartum visit. METHODS: We conducted a quasiexperimental before-after study to evaluate long-acting reversible contraception initiation, specifically an intrauterine device or contraceptive implant, at the postpartum visit between women scheduled for follow-up at 6 weeks (before policy change) and 2-3 weeks after delivery (after policy change). Secondary outcomes included postpartum visit completion, overall contraception initiation at the postpartum visit, overall contraceptive use at 6 months after delivery, and repeat pregnancies by 6 months postpartum. We obtained delivery and postpartum information using the electronic medical record and contacted participants 3 and 6 months after delivery to assess contraception use and repeat pregnancies. RESULTS: We enrolled 586 participants between December 2014 and November 2015, of whom 512 women (256 in each cohort) continued to meet eligibility criteria after delivery. Long-acting reversible contraception initiation rates at the postpartum visit were lower in the 2- to 3-week (16.5%, 95% CI 12.2-21.8) compared with the 6-week group (31.1%, 95% CI 25.2-37.7, P<.01), primarily as a result of patient and health care provider preferences for delaying intrauterine device insertion to a later visit. More women completed a scheduled 2- to 3-week postpartum visit (90.2%, 95% CI 86.0-93.3) compared with a 6-week visit (81.6%, 95% CI 76.4-85.9, P<.01). Deferral of any contraception initiation was higher in the 2- to 3-week group (27.3%, 95% CI 21.9-33.4) compared with the 6-week group (15.8%, 95% CI 11.5-21.4, P<.01), but there were no differences in overall contraceptive use patterns at 6 months postpartum. No intrauterine device perforations or expulsions were observed in women who underwent insertion at 2-3 weeks postpartum. Five pregnancies were reported in each cohort by 6 months after delivery. CONCLUSION: Scheduling a visit at 2-3 weeks after delivery was not associated with increased long-acting reversible contraception initiation at this visit despite higher postpartum visit attendance.

The Use of Transvaginal Ultrasound in Type II Endometrial Cancer.

OBJECTIVE: To determine the use of the transvaginal ultrasound (TVUS) in postmenopausal women with type II endometrial cancer. METHODS/MATERIALS: A retrospective review was conducted for 173 women with pathology proven type II endometrial cancer at a single institution. Those who underwent preoperative TVUS were included, and the following data were obtained: endometrial stripe (EMS) measurement, uterine and/or adnexal findings, and uterine size/volume. Clinicopathologic factors were abstracted. Descriptive and regression analyses were performed. RESULTS: Fifty-eight women comprised the cohort, and the median age was 66.5 years (50-85 years). The most commonly reported symptom was postmenopausal bleeding in 53 patients (91.4%). The EMS was reported as thin (≤ 5 mm) or indistinct in 16 patients (27.5%). Approximately 60% of patients had 1 or more ultrasound abnormalities: intracavitary mass (31%), intracavitary fluid (12.1%), myometrial lesion (31.03%), and adnexal mass (12.1%). Poorly differentiated endometrioid cancer (53.45%) represented the predominant histology. Of the 16 (27.5%) women with a thin/indistinct EMS, 5 women (8.6%) did not have any abnormal ultrasound findings whatsoever. CONCLUSIONS: Women with type II endometrial cancer had a thin/indistinct EMS on TVUS in approximately 25% of cases. Lack of any ultrasound abnormality, including a thickened EMS, was noted in approximately 10% of patients. The use of TVUS, which has been of value in type I cancer, is limited in type II endometrial cancer. Therefore, endometrial sampling should be included in the evaluation of all women with postmenopausal bleeding, regardless of EMS thickness.