Exploring Reasons for Loss to Follow-up in Pregnancy of Unknown Location: A Mixed-Methods Study.

Objective: To quantify proportions of loss to follow-up in patients presenting with a pregnancy of unknown location and explore patients' perspectives on follow-up for pregnancy of unknown location. A pregnancy of unknown location is a scenario in which a patient has a positive pregnancy test but the pregnancy is not visualized on transvaginal ultrasound. Study Design: We conducted a retrospective cohort study of patients with pregnancy of unknown location who presented to an urban academic emergency department or complex family planning outpatient office. We sought to calculate the proportion of patients lost to follow-up, defined as inability to contact the patient within 2 weeks. We then conducted focus groups of patients diagnosed with a pregnancy of unknown location. We used thematic analysis to identify themes related to follow-up. Results: We reviewed 464 charts of patients diagnosed with pregnancy of unknown location. The median age in this cohort was 27 with most patients identifying as Black (80%, n = 370) and using public insurance (67%, n = 315). When looking at loss to follow-up rates, Black patients experienced loss to follow-up (20%, n = 72) more often than White patients (4%, n = 2; p = 0.003). Focus group participants had a mean age of 31.8+/-4.8, and the majority were of Black race (n = 16, 72.7%). Participants identified barriers to follow-up including the long duration of management, general inconvenience, and poor communication with their health care team. Participants felt a burden of responsibility to learn about their condition and to self-advocate for their follow-up and communication of results. Conclusions: These data indicate that Black patients are more likely to experience loss to follow-up compared with White patients during monitoring for pregnancy of unknown location. Patients identified many barriers to follow-up and felt that successful follow-up required substantial self-efficacy.

Evaluation of a decision aid for early pregnancy loss: A pilot randomized controlled trial in Philadelphia, Pennsylvania.

OBJECTIVES: To evaluate the effect of a decision aid on decisional conflict scale in patients choosing management for early pregnancy loss. STUDY DESIGN: We conducted a pilot randomized control trial to assess the effect of the Healthwise patient decision aid on decisional conflict scale in patients with early pregnancy loss as compared with a control website. Patients 18years and older were eligible if they had an early pregnancy loss between 5 and 12 completed weeks of gestation. Participants completed surveys at baseline, poststudy intervention, after consultation, and 1week postconsultation. Surveys assessed participant scores on the decisional conflict scale (scale 0-100), knowledge, assessment of shared decision-making, satisfaction, and decision regret. Our primary outcome was the poststudy-intervention decisional conflict scale score. RESULTS: From July 2020 through March 2021 we randomized 60 participants. After the intervention, the median decisional conflict scale score for the control group was 10 [0-30] and 0 [0-20] for the intervention group (p = 0.17). When assessing the decisional conflict scale subscales postintervention, the informed subscale for the control group was 16.7 [0-33.3] as opposed to 0 [0] for the patient decision aid group (p = 0.003). Knowledge remained significantly higher in the experimental arm from the postintervention to the 1-week follow-up. We found no differences between groups when assessing our other metrics. CONCLUSIONS: Use of a validated decision aid did not result in statistically significant differences in the total decisional conflict scale scores as compared with the control. Participants allocated to the intervention were more informed postintervention and had consistently higher knowledge scores. IMPLICATIONS: Use of a validated decision aid prior to early pregnancy loss management consultation did not affect overall decisional conflict but resulted in improved knowledge.

Perceptions of HIV risk screening strategies among patients seeking abortion, contraception, and pregnancy loss management in the United States.

OBJECTIVES: Women make up nearly a fifth of new human immunodeficiency virus (HIV) infections yearly in the United States, more than half of which could have been prevented with broader use of HIV pre-exposure prophylaxis (PrEP). We aimed to qualitatively assess (1) acceptability of an HIV risk screening strategy and PrEP provision in a family planning setting, and (2) the influence of family planning visit type (abortion, pregnancy loss management, or contraception) on HIV risk screening acceptability. STUDY DESIGN: Guided by the P3 (practice-, provider-, and patient-level) model for preventive care interventions, we conducted three focus group discussions including patients who had experienced induced abortion, early pregnancy loss (EPL), or contraception care. We developed a codebook of a priori and inductive concepts, and categorized themes by practice, provider, and patient considerations. RESULTS: We included 24 participants. Practice-level considerations included overall positive feelings about being screened for PrEP eligibility during family planning visits, though some expressed reservations about screening during EPL visits. Provider-level themes included the concept of screening tools as entry points into conversation and education, and the importance of nonjudgment in discussing sexually transmitted infection (STI) prevention. Participants often had to initiate STI prevention discussions and felt that contraception was overemphasized by their providers compared with STI prevention and PrEP care. Patient-level themes included the stigma of STIs and oral PrEP, and the dynamic nature of STI risk. CONCLUSIONS: Participants in our research had genuine interest in learning about PrEP during family planning visits. Findings from our research support the consistent inclusion of STI prevention education into family planning clinical practice using patient-centered STI screening methods. IMPLICATIONS: Family planning encounters, including visits for contraception and abortion, are generally appropriate times to discuss HIV PrEP. Patient-centered conversations are an important adjunct to HIV risk screening tools.

Sex as an Independent Risk Factor for Venous Thromboembolism in Sickle Cell Disease: A Cross-Sectional Study.

Venous thromboembolism (VTE) affects up to 25% of individuals with sickle cell disease (SCD), but risk factors are not well characterized. We sought to measure the prevalence of VTE among SCD patients in our health system and to describe the relationship between medical history, biological sex, and VTE. We performed a retrospective chart review of SCD patients who visited an outpatient hematology clinic within Penn Medicine between June 2014 and June 2019. Demographics and medical history were compared across those with and without a history of VTE. We developed a logistic regression model to describe factors independently associated with VTE. Of 597 patients with SCD who were identified, 147 (24.6%) had a history of VTE; 100 were female and 47 were male. In the regression model, female sex was independently associated with history of VTE (odds ratio 1.91, 95% confidence interval 1.26-2.91), as were pulmonary hypertension, hydroxyurea use, and history of stroke. Among females only, 49.7% were parous and 18.8% had used oral contraceptives, and these proportions did not differ by history of VTE. One-quarter of the SCD patients in our health system had a history of VTE, confirming significantly higher rates than in the general population. Females had twice the odds of VTE compared to males, highlighting an important sex disparity in SCD disease outcomes and raising questions regarding optimal pregnancy and contraceptive care for females with SCD.

Implementation of an HIV Pre-exposure Prophylaxis Strategy Into Abortion and Early Pregnancy Loss Care.

BACKGROUND: Family planning and abortion clinics routinely address sexual health. We sought to evaluate implementation outcomes of an HIV pre-exposure prophylaxis (PrEP) care strategy for patients seeking management of induced abortion and pregnancy loss. SETTING: Single-center, urban, academic, hospital-based family planning service. METHODS: We used a multifaceted implementation strategy directed toward family planning providers comprised of educational sessions, an electronic medical record-prompted verbal assessment of HIV risk, electronic medical record shortcuts for PrEP prescription, and support of a PrEP navigator. We assessed penetration of the intervention by calculating the penetration of a PrEP offer, measured as the proportion of encounters in which PrEP was offered to PrEP-eligible individuals. We evaluated feasibility, acceptability, and appropriateness of the intervention using belief elicitation interviews with providers. RESULTS: From November 2018 to April 2019, the proportion of PrEP eligible patients who were offered PrEP, was 87.9% (29/33). Providers found the intervention acceptable and appropriate, but reported barriers including time constraints, and disappointment if patients did not adhere to PrEP. Providers liked that PrEP provision in abortion care settings felt innovative, and that they could contribute to HIV prevention. CONCLUSION: Family planning providers in an academic center found HIV risk assessment and PrEP provision to be feasible, acceptable, and appropriate. Further research should evaluate implementation outcomes of PrEP care strategies in additional abortion care contexts, including clinics offering reproductive health care outside of academia.

Incorporating HIV Pre-Exposure Prophylaxis Care for Patients Seeking Induced Abortion and Pregnancy Loss Management.

BACKGROUND: Family planning clinical encounters are important opportunities for HIV prevention. Our objectives were to 1) estimate the proportion of patients seeking induced abortion and early pregnancy loss management eligible for HIV pre-exposure prophylaxis (PrEP) and 2) compare PrEP eligibility and uptake between patients with unintended and intended pregnancy. METHODS: We conducted a cross-sectional survey and a nested prospective cohort study of patients seeking an induced abortion or early pregnancy loss management. We assessed pregnancy intendedness, PrEP awareness, HIV risk and risk perception, desire for same-day PrEP start, and PrEP continuation at 30 days. We used the χ2 and Fisher's exact tests to assess differences between the participants with intended and unintended pregnancy. We had 80% power to detect a 14% difference in PrEP eligibility between the groups. RESULTS: We enrolled 250 women. Fifty-six percent (139) had an unintended pregnancy and 44% (110) had an intended pregnancy. PrEP eligibility did not differ significantly between the patients with intended and unintended pregnancy (16% vs. 10%; p = .18). More than one-half (54%, 135/250) were unaware of PrEP before their study visit, and 93% (232/250) considered themselves unlikely to acquire HIV. Of 33 women who were PrEP eligible, 11 accepted same-day start and 1 continued PrEP at 30 days. CONCLUSIONS: Intendedness of pregnancy was unrelated to PrEP eligibility in women seeking induced abortion and early pregnancy loss management. Most patients seeking these services are unaware of PrEP. Integrating PrEP into family planning care is likely to increase awareness and uptake of PrEP in women.