Medical Compared With Surgical Abortion for Effective Pregnancy Termination in the First Trimester.

OBJECTIVE: To compare efficacy between medical and surgical abortion at 9 weeks of gestation or less. METHODS: We performed a retrospective cohort study comparing efficacy of medical compared with surgical abortion before 64 days of gestation at Planned Parenthood, Los Angeles, from November 2010 to August 2013. Electronic medical records were reviewed for ongoing pregnancies after the initial abortion procedure. Data were also collected on complications occurring within the immediate postabortal period (8 weeks postabortal) including unanticipated aspiration and major adverse events (emergency department presentation, hospitalization, perforation, transfusion, infection). Chi square test and logistic regression were used to compare the primary outcomes between cohorts. RESULTS: Data were collected from 30,146 women with pregnancies seeking termination before 64 days of gestation. Sociodemographic and clinical characteristics were similar in the medication and surgical abortion groups. Efficacy of pregnancy termination was 99.6% for medication abortions and 99.8%% for surgical abortions (P<.001). The medication abortion group was more likely to undergo an unanticipated aspiration, for ongoing pregnancy or persistent pain, bleeding, or both (2.1% compared with 0.6%, respectively, odds ratio 1.6, 95% confidence interval 1.1-2.3). These rates were unchanged after controlling for gravidity, parity, and body mass index. There was no difference in major adverse events between the two groups. CONCLUSION: Medication abortion and surgical abortion before 64 days of gestation are both highly effective with low complication rates. LEVEL OF EVIDENCE: II.

Efficacy and safety of medical abortion using mifepristone and buccal misoprostol through 63 days.

OBJECTIVE: The aim of this study was to report on the safety and efficacy of an evidence-based medical abortion regimen utilizing 200 mg of mifepristone orally followed by home use of 800 mcg misoprostol buccally 24-48 h later through 63 days estimated gestational age. STUDY DESIGN: We analyzed outcomes in women presenting for medical abortion between April 1, 2006, and May 31, 2011, using an evidence-based alternative to the United States Food and Drug Administration (FDA)-approved regimen. Cases were identified for this descriptive study from our electronic practice management (EPM) database, and our electronic database on adverse events was queried for information on efficacy and safety. The primary outcome was successful abortion. Logistic regression was used to identify predictors of successful abortion. RESULTS: Among the 13,373 women who completed follow-up, efficacy of the regimen was 97.7%. Efficacy was highest at 29 to 35 days (98.8%) and 36 to 42 days (98.8%) of gestation and lowest at 57 to 63 days (95.5%). The odds of needing aspiration for any reason were greatest at higher gestational ages. Rates of infection requiring hospitalization and rates of transfusion were 0.01 and 0.03%, respectively. CONCLUSIONS: An evidence-based regimen of 200 mg of mifepristone orally followed by home use of 800 mcg of buccal misoprostol 24-48 h later is safe and effective through 63 days estimated gestational age. Further, the need for aspiration for any reason was low, and hospitalization was rare. IMPLICATIONS: This study reinforces the safety and efficacy of the evidence-based regimen for medical abortion (200 mg mifepristone orally followed by home use of 800 mcg of misoprostol buccally 24-48 h later) through 63 days estimated gestational age, and contributes to the existing evidence against restrictions requiring use of the FDA-approved regimen.

Relationship between ultrasound viewing and proceeding to abortion.

OBJECTIVE: Ultrasound scanning is a routine part of preprocedure abortion care, and many health care providers offer patients the opportunity to view their ultrasound images. It has been speculated that ultrasound viewing will dissuade women from having an abortion. We examine whether viewing the image is associated with choosing to continue the pregnancy. METHODS: Data from medical records for 15,575 visits by women seeking abortion care at a large, urban abortion provider in 2011 were analyzed for factors associated with choosing to continue the pregnancy. All patients received a preprocedure ultrasound scan and were offered the opportunity to view the image. RESULTS: Patients opted to view the ultrasound image 42.5% of the time. Nearly all pregnancies (98.8%) were terminated: 98.4% of pregnancies among women who viewed their ultrasound images and 99.0% of pregnancies among the patients who did not. Among women with high decision certainty, viewing was not associated with deciding to continue the pregnancy. Viewing was significantly associated with deciding to continue the pregnancy only among the 7.4% of women who reported medium or low decision certainty about having an abortion (adjusted odds ratio 3.21, 95% confidence interval 1.18-8.73). CONCLUSION: Voluntarily viewing the ultrasound image may contribute to a small proportion of women with medium or low decision certainty deciding to continue the pregnancy; such viewing does not alter decisions of the large majority of women who are certain that abortion is the right decision. LEVEL OF EVIDENCE: II.

Patient viewing of the ultrasound image prior to abortion.

BACKGROUND: Little research has investigated women's interest in and factors associated with viewing their ultrasound image in abortion care. STUDY DESIGN: Using medical records for all abortion care visits in 2011 (n = 15,575) at an urban abortion provider, we determined the proportion of women who chose to view by sociodemographic and pregnancy-related characteristics. We used bivariate and multivariable mixed-effects logistic regression models to examine associations between individual-level factors and the decision to view. RESULTS: A total of 42.6% of women chose to view. Identifying as nonwhite, being under age 25, being at or below the federal poverty level, and having medium or low decision certainty about the abortion were associated with increased odds of viewing. Being age 30 and over, having previously been pregnant and being more than 9 weeks gestation were associated with decreased odds of viewing. CONCLUSIONS: Many women seeking abortion care want to view their ultrasound image when offered the opportunity.

Eliminating the routine postoperative surgical abortion visit.

BACKGROUND: The objective of this study was to determine whether replacing the "routine" postoperative visit after surgical abortion with an "as indicated" visit is associated with an increase in the rates of either failed abortion (continuing pregnancy) or repeat abortion. METHODS: We compared the rate of continuing pregnancy in 50,702 first-trimester surgical abortion patients who were offered routine postoperative visits in one time period (1/1/00-4/30/07) to the rate in 20,315 first-trimester surgical abortion patients from a later time period (5/1/07-12/31/09) in which routine postoperative visits had been discontinued. We also compared the rate of repeat abortion within 1 year of the initial procedure for both first- and second-trimester surgical abortion patients for the same time periods. RESULTS: The rate of continuing pregnancy remained stable before and after routine visits were discontinued (39.4 per 100,000 first-trimester surgical abortions for each group).The rate of repeat abortion within 1 year after the initial procedure was lower after routine visits were discontinued (8.2%) than before routine visits were discontinued (8.7%), p=.007. CONCLUSION: We conclude that elimination of the routine postoperative visit after a surgical abortion and the substitution of an "as indicated" postoperative visit are not associated with an increase in either continuing pregnancies or repeat abortion.

Infection and extramural delivery with use of digoxin as a feticidal agent.

BACKGROUND: Many abortion providers use digoxin to induce fetal demise prior to dilation and evacuation (D&E). Our primary objective was to examine the frequency of infection and extramural delivery following digoxin use. STUDY DESIGN: We conducted a retrospective single-cohort study. Inclusion criteria were all women between 18 and 24 weeks of estimated gestational age who received digoxin in preparation for D&E at our outpatient facility. We queried two electronic databases to collect data on the frequency of extramural delivery and the rate of perioperative infection. RESULTS: From January 1, 2000, to December 31, 2008, 4906 abortions were performed between 18 and 24 weeks of estimated gestation with digoxin injection administered as feticidal agent 1 day prior to D&E. Extramural delivery frequency was 0.30%, and infection frequency was 0.04%. There were no significant differences in the frequency of extramural deliveries across procedure year (p = .2), estimated gestational age (p = .3), race/ethnicity (p = .2) or maternal age (p = .3). CONCLUSION: Rates of extramural delivery and infection are acceptably low following digoxin use prior to scheduled D&E.

A randomized pilot study on the effectiveness and side-effect profiles of two doses of digoxin as fetocide when administered intraamniotically or intrafetally prior to second-trimester surgical abortion.

BACKGROUND: Digoxin is commonly used to facilitate second-trimester surgical abortion despite limited data regarding its safety and effectiveness for this indication. We conducted a pilot study to determine the incidence of side effects after digoxin administration and whether effectiveness can be improved with variations in dose and technique. STUDY DESIGN: Fifty-two women presenting for elective termination of pregnancy between 18 and 24 weeks' gestation were randomized to one of four digoxin treatment groups: 1.0 mg intraamniotic (1.0 IA), 1.0 mg intrafetal (1.0 IF), 1.5 mg intraamniotic (1.5 IA) or 1.5 mg intrafetal (1.5 IF). Ultrasound was used to assess for the presence of fetal cardiac activity prior to the abortion procedure. Data on the presence and severity of pain, nausea and other potential side effects were collected before digoxin injection, immediately following digoxin injection and on the day after digoxin injection. RESULTS: Digoxin effectively induced fetal death in 87% of women. The failure rate did not vary by route of administration (IA or IF) and was not lowered by increasing the dose from 1.0 to 1.5 mg. IF injections induced fetal death more rapidly than IA injections. Digoxin administration did not result in increased pain or nausea. CONCLUSIONS: IA or IF injection of digoxin is safe and effective for inducing fetal death prior to second-trimester surgical abortion. Doses greater than 1.0 mg may not be necessary.

Serious adverse events associated with the use of misoprostol alone for cervical preparation prior to early second trimester surgical abortion (12-16 weeks).

BACKGROUND: The purpose of this study was to determine the rate of serious adverse events (SAEs) occurring during early second trimester surgical abortion performed following the use of misoprostol alone for cervical preparation. STUDY DESIGN: A retrospective review was undertaken of 6620 elective surgical abortions performed between 12 and 16 weeks estimated gestational age during a 68-month period following cervical preparation with misoprostol alone. Information was obtained from a computer-based practice management system. RESULTS: During the study period, four SAEs occurred: three uterine perforations and one case of hemorrhage secondary to placenta accreta. The perforation rate was 0.45 (95% CI=0.09-1.32) per 1000 abortions. CONCLUSION: This review of our experience with surgical abortion performed from 12 to 16 weeks estimated gestational age following cervical preparation with misoprostol alone shows that the rate of SAEs, specifically uterine perforation, in this group was no greater than that previously reported in the literature.

Chlamydia heat shock protein 60 induces trophoblast apoptosis through TLR4.

Intrauterine infection affects placental development and function, and subsequently may lead to complications such as preterm delivery, intrauterine growth retardation, and preeclampsia; however, the molecular mechanisms are not clearly known. TLRs mediate innate immune responses in placenta, and recently, TLR2-induced trophoblast apoptosis has been suggested to play a role in infection-induced preterm delivery. Chlamydia trachomatis is the etiological agent of the most prevalent sexually transmitted bacterial infection in the United States. In this study, we show that in vitro chlamydial heat shock protein 60 induces apoptosis in primary human trophoblasts, placental fibroblasts, and the JEG3 trophoblast cell line, and that TLR4 mediates this event. We observed a host cell type-dependent apoptotic response. In primary placental fibroblasts, chlamydial heat shock protein 60-induced apoptosis was caspase dependent, whereas in JEG3 trophoblast cell lines it was caspase independent. These data suggest that TLR4 stimulation induces apoptosis in placenta, and this could provide a novel mechanism of pathogenesis for poor fertility and pregnancy outcome in women with persistent chlamydia infection.

Adequacy and safety of buccal misoprostol for cervical preparation prior to termination of second-trimester pregnancy.

OBJECTIVE: The objective of this retrospective, descriptive study is to assess the adequacy and safety of buccal misoprostol with and without laminaria for cervical preparation prior to second-trimester abortion. METHODS: We analyzed Planned Parenthood Federation of America data from 2,218 elective dilation and evacuation (D&E) procedures conducted on women at 12 to 23 6/7 weeks of gestation from April 2002 to March 2003. Each woman received 400, 600 or 800 microg of buccal misoprostol with or without laminaria for preprocedural cervical preparation. RESULTS: Of the patients, 62% received 400 mug, 32% received 600 microg and 6% received 800 microg of buccal misoprostol; 42.8% had laminaria inserted for phased cervical preparation. The adequacy of cervical dilation was 88.7%. The D&E procedure was completed during a single surgical procedure for 99.8%. The overall adverse event rate was 19.39 per 1,000 women, with a rate of 4.51 per 1,000 women for serious adverse events. CONCLUSIONS: This descriptive study suggests that use of buccal misoprostol with or without laminaria is effective and safe. If buccal misoprostol eliminates or reduces the need for phased, multiday laminaria 1-3 days prior to the surgical procedure, then its use may offer service advantages such as reduced number of clinic visits and fewer pelvic examinations per woman.