Dextromethorphan as a novel nonopioid adjunctive agent for pain control with medication abortion: A randomized controlled trial.

OBJECTIVES: To evaluate efficacy and satisfaction of dextromethorphan as a non-narcotic adjuvant to current analgesic regimens for medication abortion. STUDY DESIGN: We conducted a randomized, double-blinded, placebo-controlled trial. We randomized eligible participants (N = 156) 1:1 to adjunctively take dextromethorphan (loading dose 60 mg and two subsequent 30 mg doses at 2 and 5 hours after misoprostol administration) or placebo combined with usual-care nonsteroidal anti-inflammatory medications ± opioids for pain. Participants reported pain scores and satisfaction using a secure texting application at 2, 5, 8, and 24 hours after misoprostol administration. Our primary outcome was worst pain score and total analgesic use. RESULTS: Baseline demographics of enrolled participants were similar between randomization arms. Worst pain scores for participants receiving dextromethorphan versus placebo (8.0 vs 7.0, p = 0.06) did not differ. Total milligram usage of ibuprofen (800 mg vs 610 mg, p =.62), acetaminophen (1000 mg vs 1300 mg, p = 0.62), and opioids (10 mg vs 15 mg, p = 0.51) did not differ between the randomization groups. Participants randomized to placebo were significantly more likely to be satisfied with their pain control (91% vs 75%, p = 0.02). CONCLUSION: Dextromethorphan used adjunctively with standard analgesics did not reduce pain associated with medication abortion. Participants who received dextromethorphan reported decreased satisfaction with their pain control. IMPLICATIONS: Dextromethorphan used adjunctively with commonly used analgesic regimens did not reduce medication abortion associated pain. Many participants did not use analgesics as counseled, and nearly 25% used no analgesia during medication abortion.

A mystery shopper study identifying practice-level barriers to adolescent IUD access in western Pennsylvania.

OBJECTIVE(S): To identify practice-level barriers that adolescents experience when seeking a hormonal intrauterine device (IUD). STUDY DESIGN: We secret-shopped gynecological practices within a health system using a script targeting potential practice-level barriers. RESULTS: We assessed 50 of a targeted 50 practices; only 8 (16%) would schedule a contraceptive appointment that permitted same-day IUD placement. Twenty-eight (56%) respondents stateda parent must accompany the adolescent. CONCLUSION: Practice-level barriers toadolescentIUD access exist that are inconsistent with best-practice guidelines and Pennsylvania state law. IMPLICATIONS: Practice staff and providers need more medical and legal education regarding IUD provision to adolescents.

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.

The Quality of Health Information Available on the Internet for Patients With Pelvic Organ Prolapse.

OBJECTIVE: This study aimed to assess the quality of Web sites that provide information on pelvic organ prolapse using validated quality measurement tools. METHODS: The Google search engine was used to perform a search of the following 4 terms: "pelvic organ prolapse," "dropped bladder," "cystocele," and "vaginal mesh." The DISCERN appraisal tool and JAMA benchmark criteria were used to determine the quality of health information of each Web site. Cohen κ was performed to determine interrater reliability between reviewers. Kruskal-Wallis and Wilcoxon rank sum tests were used to compare DISCERN scores and JAMA criteria among search terms. RESULTS: Interrater reliability between the two reviewers using DISCERN was κ = 0.71 [95% confidence interval (CI), 0.68-0.74] and using JAMA criteria was κ = 0.98 (95% CI, 0.74-1.0). On the basis of the DISCERN appraisal tool, the search term "vaginal mesh" had significantly lower Web site quality than "pelvic organ prolapse" and "cystocele," respectively [mean difference of DISCERN score, -14.65 (95% CI, -25.50 to 8.50, P < 0.0001) and -12.55 (95% CI, -24.00 to 7.00, P = 0.0007)]. "Dropped bladder" had significantly lower Web site quality compared to "pelvic organ prolapse" and "cystocele," respectively (mean difference of DISCERN score, -9.55 (95% CI, -20.00 to 3.00, P = 0.0098) and -7.80 (95% CI, -18.00 to 1.00, P = 0.0348). Using JAMA criteria, there were no statistically significant differences between Web sites. CONCLUSIONS: Web sites queried under search terms "vaginal mesh" and "dropped bladder" are lower in quality compared with the Web sites found using the search terms "pelvic organ prolapse" and "cystocele."

Cervical preparation for second-trimester surgical abortion prior to 20 weeks' gestation: SFP Guideline #2013-4.

For a dilation and evacuation (D&E) procedure, the cervix must be dilated sufficiently to allow passage of operative instruments and products of conception without injuring the uterus or cervical canal. Preoperative preparation of the cervix reduces the risk of cervical laceration and uterine perforation. The cervix may be prepared with osmotic dilators, pharmacologic agents or both. Dilapan-S™ and laminaria are the two osmotic dilators currently available in the United States. Laminaria tents, made from dehydrated seaweed, require 12-24 h to achieve maximum dilation. Dilapan-S™, made of synthetic hydrogel, achieves significant dilation within 4 h and is thus preferable for same-day procedures. A single set of one to several dilators is usually adequate for D&E before 20 weeks' gestation. Misoprostol, a prostaglandin E1 analogue, is sometimes used instead of osmotic dilators. It is generally regarded as safe and effective; however, misoprostol achieves less dilation than overnight osmotic tents. The literature supports same-day cervical preparation with misoprostol or Dilapan-S™ up to 18 weeks' gestation. As the evidence regarding alternative regimens increases, highly experienced D&E providers may consider same-day regimens at later gestations utilizing serial doses of misoprostol or a combination of osmotic and pharmacologic agents. Misoprostol use as an adjunct to overnight osmotic dilation is not significantly beneficial before 19 weeks' gestation. Limited data demonstrate the safety of misoprostol before D&E in patients with a prior cesarean delivery. Mifepristone, a progesterone receptor antagonist, is also effective for cervical preparation prior to D&E, although data to support its use are limited. The Society of Family Planning recommends preoperative cervical preparation to decrease the risk of complications when performing a D&E. Since no single protocol has been found to be superior in all situations, clinical judgment is warranted when selecting a method of cervical preparation.

Contraceptive options for women with a history of solid-organ transplantation.

Women of reproductive age who have received a solid-organ transplant are at risk for unplanned pregnancy. Fertility can return as soon as 1 month after transplantation, and the baseline unplanned pregnancy rate in the United States is approximately 50%. Pregnancy, although not absolutely contraindicated in this population, carries risk greater than the general population and should be timed with regard to medication regimen and organ function. The Centers for Disease Control categorizes every form of contraception as Category 2-benefits outweigh risks-in women with an uncomplicated transplantation. There is a large range of contraceptive options, varying in drug formulation, route of delivery, and discrepancy between "perfect" and "typical" use. Long-acting reversible contraceptive methods include intrauterine devices (IUDs) and subdermal implants and show great promise for women with solid-organ transplant. These methods have excellent efficacy, eliminate user error, and, in the case of IUDs, have extremely low or no systemic drug absorption. Providers have historical concerns regarding the association of IUD and infection; however, modern studies have shown their safety in both immunocompetent and immunocompromised patients. Women with a history of solid-organ transplantation can be safely offered a wide range of contraceptive options to suit their individualized needs.