Duration of Induction of Labor for Second-Trimester Medication Abortion and Adverse Outcomes.

OBJECTIVE: To evaluate the relationship between duration of labor during second-trimester medication abortion and adverse outcomes. METHODS: We conducted a retrospective cohort study including all individuals with a singleton gestation undergoing second-trimester medication abortion without evidence of advanced cervical dilation, rupture of membranes, or preterm labor at four centers. The primary exposure was duration of labor (ie, hours spent from receiving misoprostol to fetal expulsion). The primary outcome was composite morbidity, defined as uterine rupture, need for blood transfusion, clinical chorioamnionitis, intensive care unit admission, or need for readmission. We performed bivariate and multivariate negative binomial analyses. A post hoc subgroup analysis was performed to assess for the risk of the primary outcome by gestational age. We performed tests of homogeneity based on history of uterine scarring and parity. RESULTS: Six hundred eighty-one individuals were included. The median duration of labor was 11 hours (interquartile range 8-17 hours). One hundred thirty-one (19.2%) experienced the primary outcome. When duration of labor was evaluated continuously, a longer duration of labor was associated with an increased frequency of morbidity (adjusted ß=0.68, 95% CI, 0.32-1.04). When duration of labor was evaluated categorically, those experiencing the highest quartile of duration (ie, 17 hours or more) had a statistically higher risk for experiencing morbidity compared with individuals in all other quartiles (adjusted relative risk 1.99, 95% CI, 1.34-2.96). When we focused on components of the composite outcome, clinical chorioamnionitis was significantly different between those experiencing a longer duration and those experiencing a shorter duration of labor (26.2% vs 10.6%, P<.001). On subgroup analysis, gestational age was not associated with the risk of composite morbidity. Tests of homogeneity demonstrated no significant difference in the risk for morbidity among individuals with a history of uterine scarring or based on parity. CONCLUSION: Duration of labor was independently associated with risks for adverse maternal outcomes during second-trimester medication abortion, specifically clinical chorioamnionitis.

Complications of second-trimester medical termination of pregnancy for fetal anomalies compared with intrauterine fetal demise.

OBJECTIVE: To assess complication rates of patients undergoing a second-trimester medical termination for intrauterine fetal demise compared with fetal anomalies. METHODS: We performed a retrospective cohort study comparing patients undergoing medical termination for a fetal anomaly versus medical termination for intrauterine fetal demise (IUFD) before 24 weeks of gestation. Data were collected from two urban academic medical centers from 2009 to 2019. Institutional review board approval was obtained from both institutions and patient consent was not required. We included singleton gestations between 14.0 weeks and 23.6 weeks undergoing induction with mifepristone and misoprostol or misoprostol alone. Groups were matched based on gestational age with a 1:1 ratio. The primary outcome was composite complication rate (retained placenta requiring dilation and curettage, suspected infection, hemorrhage, failed induction requiring dilation and evacuation, intensive care unit admission, and readmission). RESULTS: Ninety-five patients were in each group. The groups differed in patient mean age (fetal anomaly 34 years versus 31 years for IUFD, P = 0.005) and mifepristone pretreatment (fetal anomaly 55% versus IUFD 5%, P < 0.001). Composite complication rate was similar (fetal anomaly 14% versus IUFD 17%), and specific complications did not differ. CONCLUSION: Second-trimester medical termination for IUFDs have similar complication rates as those undergoing induction terminations for fetal anomalies.

Complications of second trimester induction for abortion or fetal demise for patients with and without prior cesarean delivery.

OBJECTIVE: Compare complication rates of second trimester induction for abortion or fetal demise for patients with and without prior cesarean delivery. STUDY DESIGN: Retrospective cohort study examining induction for abortion or fetal demise for pregnancies from 14w0d to 23w6d gestation at 2 urban academic medical centers from 2009 to 2019. Exclusion criteria included preterm labor or cervical insufficiency, neonatal interventions, or if misoprostol was not the primary induction method. Complication rates were compared between those with no prior, 1 prior, and 2 or more (2+) prior cesarean deliveries. Complications analyzed were retained placenta, failed induction, infection, hemorrhage, blood transfusion, uterine rupture, intensive care unit admission, death, and readmission. Secondary analysis included cumulative misoprostol dosages and complete abortion rate within 24 hours. RESULTS: Of 520 patients, 411 patients had no prior cesarean delivery, 77 had 1 prior cesarean delivery, and 32 had 2+ prior cesarean deliveries. Eleven patients had a prior vertical uterine incision. About 26.5% of all patients received mifepristone. The 2+ prior cesarean delivery group was significantly older (35 vs 32 vs 32, p < 0.001) and more likely to be induced for fetal demise (62.5 vs 41.56 vs 39.17%, p = 0.04). Both cesarean groups were more likely to be obese (58.62 vs 49.35 vs 34.26%, p = 0.003). Patients with 2+ prior cesarean deliveries were more likely to experience uterine rupture (6.25 vs 0 vs 0%, p = 0.004), and require ICU admission (6.45 vs 1.3 vs 0.49%, p = 0.02). Secondary analysis outcomes were similar. Logistic regression showed patients with 2+ prior cesarean deliveries were more likely to experience a complication than those with 1 prior (adjusted odds ratio [aOR] 2.71, confidence interval [CI] 1.09-6.86, p = 0.03) or 0 prior cesarean deliveries (aOR 3.00, CI 1.30-7.02, p = 0.01). Patients with 1 prior or no prior cesarean deliveries had a similar risk of experiencing a complication (aOR 1.11, CI 0.64-1.89, p = 0.7). CONCLUSIONS: Most patients with prior cesarean deliveries can safely undergo induction in the second trimester for abortion or fetal demise. Patients with 2+ prior cesarean deliveries had a higher rate of at least 1 complication when compared to those with one or no prior cesarean delivery, despite similar misoprostol dosages and rates of complete abortion. IMPLICATIONS: This large 10-year retrospective study examines the impact of prior cesarean delivery on the safety of second trimester induction. While second trimester labor induction abortion remains an option for all patients, specialized counseling for patients with 2 or more prior cesarean deliveries may be warranted.

Comparison of vaginal and buccal misoprostol after mifepristone for medication abortion through 70 days of gestation: A retrospective chart review.

OBJECTIVE: To determine the proportion of complete abortion without surgical intervention for patients who chose medication abortion with vaginal compared to buccal misoprostol following oral mifepristone through 70 days of gestation. METHODS: We performed a retrospective cohort study. We reviewed charts via electronic medical record data abstraction of patients receiving medication abortion with mifepristone and buccal or vaginal misoprostol between September 1, 2017 and August 1, 2019. Primary outcome was complete abortion without surgical intervention for any indication. Secondary outcomes were ongoing pregnancy and uterine aspiration for indications other than ongoing pregnancy. RESULTS: There were 14,504 encounters included in the data set. Of the 4814 patients who took vaginal misoprostol and the 4011 patients who took buccal misoprostol for whom follow up data is available, 4640 (96.4%) and 3917 (97.7%) had a complete abortion without surgical intervention, respectively (p = 0.002). At <64 days of gestation, complete abortion was 96.6% for vaginal administration compared to 98.0% for buccal (p = 0.001). At 64 to 70 days of gestation, complete abortion was 92.7% for vaginal administration compared to 93.2% for buccal (p = 0.08). Of the 1128 patients who took vaginal misoprostol at less than 6 hours after mifepristone, 95.3% experienced a complete abortion. CONCLUSION: Buccal administration of misoprostol is associated with a higher proportion of complete abortion before 64 days of gestation compared to vaginal misoprostol. Clinically, vaginal misoprostol is an effective route of administration through 70 days of gestation. IMPLICATIONS: Medication abortion with vaginal misoprostol is effective when administered through 70 days of gestation and with shorter intervals between mifepristone and misoprostol. Prospective research to better estimate effectiveness is warranted. Expanding medication abortion options promotes patient autonomy amid increasing restrictions and bans on abortion.

Community Violence Exposure and Adolescent Pregnancy in Chicago.

This study examined the association between community violence exposure (CVE), sex without contraception, and adolescent pregnancy in Chicago. A self-administered, online survey was conducted among 15- to 19-year-old girls from the South and West sides of Chicago from October to March 2018. Participants were recruited via community organization partnerships and social media advertising. The survey included questions about CVE, sexual behaviors, and covariates that are known to contribute to sexual risk taking. CVE was measured via a validated index of seven questions that measured individual experiences with violence. Multivariable and logistic regression analyses were performed to examine the association between CVE, penile-vaginal intercourse without contraception, and ever being pregnant. The final sample included 644 girls. Levels of CVE were high: 62.87% of girls reported that a close friend or relative died because of violence and 41.60% were a victim of violence. Nearly half (48.69%) of girls had penile-vaginal intercourse and 6.01% had been pregnant. For each standard deviation increase in CVE score, the odds of penile-vaginal intercourse without contraception (odds ratio [OR] = 1.69, 95% confidence interval [CI] = [1.27, 2.25]) and the odds of ever being pregnant (OR = 1.87, 95% CI = [1.36, 2.57]) increased. These results remained significant when adjusting for demographic, psychosocial, institutional, and interpersonal factors. Findings suggest that girls in Chicago who are exposed to higher levels of community violence have an increased likelihood of experiencing penile-vaginal intercourse without contraception and teenage pregnancy, even when adjusting for other predictors to teenage pregnancy.

Contraceptive Provision after Medication and Surgical Abortion.

OBJECTIVE: This study sought to compare contraception provided to patients after medication and surgical abortion. STUDY DESIGN: Women who underwent first trimester induced abortion at a university-based urban clinic between May 2009 and May 2014 were identified. Medical records were reviewed to determine the method of contraception provided by the clinic to patients after medication and surgical abortion. Postabortal contraception was defined as any contraception administered or prescribed from our health system within 4 weeks of surgical abortion or mifepristone administration. RESULTS: We reviewed 824 women who were 9 weeks gestational age or less and able to choose between medication and surgical termination of pregnancy. Overall, 587 (71.1%) had a surgical abortion and 237 (28.9%) had a medication abortion. Women who had surgical abortions were more likely to initiate long-acting reversible contraception (41.9% vs. 23.2%; p < .0001) and more likely to be provided with any type of contraception overall (83% vs. 64.6%; p < .0001). The overall follow-up rate after medication abortion was 71.7%. CONCLUSIONS: Women who had surgical abortions had a greater odds of receiving long-acting reversible contraception than those who had medication abortions. Surgical abortion patients were also more likely to be provided contraception overall. Further prospective research is needed to determine the reasons for this difference and to ensure that all patients obtain the contraception that they desire.