Society of Family Planning clinical recommendations: Pain control in surgical abortion part 2 - Moderate sedation, deep sedation, and general anesthesia.

Analgesic options for surgical abortion (also called procedural abortion) beyond local anesthesia and minimal sedation include moderate sedation, deep sedation and general anesthesia. These clinical recommendations review the effectiveness of various moderate sedation, deep sedation, and general anesthesia regimens for pain control during abortion; medication regimens used to induce analgesia and anesthesia; patient factors affecting anesthesia safety; preoperative and intraoperative protocols to reduce anesthesia risks; personnel qualifications for administration; recommended patient monitoring protocols; and general risks of anesthesia in the context of abortion care. The scope of these recommendations is based on limited available evidence and considerably relies on existing professional society guidelines and recommendations developed by content experts and reviewers. Further research to compare the efficacy and safety of different regimens is needed.

Risk factors for uterine rupture among women who attempt a vaginal birth after a previous cesarean: a case-control study.

OBJECTIVE: To identify risk factors associated with uterine rupture among term pregnancies attempting a vaginal birth after a previous cesarean. STUDY DESIGN: A case-control study was done of 348 uterine ruptures in Massachusetts between 1991 and 1998, initially screened by ICD-9 code and confirmed by medical record review, with 424 control women with a trial of labor randomly selected proportional to cases on year of delivery. Multivariable regression was used to estimate odds ratios and 95% confidence intervals. RESULTS: Successful previous vaginal birth decreased risk for uterine rupture, and gestation > 40 weeks and macrosomia increased risk. Oxytocin for induction increased risk, with a slightly lower effect when used for augmentation. Prostaglandin use in conjunction with oxytocin did not have an additive uterine rupture risk. Women using epidural analgesia have an increased uterine rupture risk. CONCLUSION: Certain labor management practices increase the risk for uterine rupture 2-3 times, although the absolute increase is small from a baseline uterine rupture rate of 0.5% to 1.0-1.5%. The association between epidural analgesia and uterine rupture deserves further study.

Ovarian hyperstimulation syndrome in a spontaneous pregnancy with a complete hydatidiform mole.

OBJECTIVE: To present a case of ovarian hyperstimulation syndrome occurring after evacuation of a spontaneously conceived hydatidiform molar pregnancy. DESIGN: Case report. SETTING: University-affiliated teaching hospital. PATIENT(S): A 19-year-old nulliparous woman who underwent vacuum curettage for a complete hydatidiform molar pregnancy was admitted to our hospital with ovarian hyperstimulation syndrome and large bilateral pleural effusions. INTERVENTION(S): Intravenous fluid, deep vein thrombosis prophylaxis, placement of bilateral chest tubes. MAIN OUTCOME MEASURE(S): Management of ovarian hyperstimulation syndrome. RESULT(S): Ultrasonography and computed tomography showed large multicystic ovaries, marked ascites, and large pleural effusions that required placement of bilateral chest tubes. She had recovered by hospital day 14. CONCLUSION(S): Ovarian hyperstimulation syndrome may develop in women who have undergone treatment for a hydatidiform mole, and serious complications may develop rapidly.

Cervical obstruction complicating second-trimester abortion: treatment with misoprostol.

BACKGROUND: Cervical cone biopsy or loop electrosurgical excision procedures (LEEP) may lead to cervical scarring, agglutination, or stenosis. Leiomyomas may also obstruct the lower uterine segment such that instruments cannot be passed from the vagina to the gestation. CASE: Two women requested second trimester abortion. Both women had undergone cervical LEEP. In addition, one woman had a 10-cm leiomyoma, which seemed to be obstructing the lower segment. In both, the external cervical os was essentially obliterated. After administration of misoprostol, the cervix softened markedly in 18-24 hours. In both women, the cervix dilated readily and allowed dilation and evacuation of the uterus. CONCLUSION: Misoprostol resulted in the ability to evacuate the uterus vaginally, in a situation that might have otherwise resulted in hysterotomy.

Where is the "W"oman in MCH?

Scientific evidence indicates that improving a woman's health before pregnancy will improve pregnancy outcomes. However, for many years, our efforts have focused primarily on prenatal care and on caring for infants after birth. The concept of preconception care has been identified repeatedly as a priority for improving maternal and infant health. Preconception care is not something new that is being added to the already overburdened healthcare provider, but it is a part of routine primary care for women of reproductive age. Many opportunities exist for preconception intervention, and much of preconception care involves merely the provider reframing his or her thinking, counseling, and decisions in light of the reproductive plans and sexual and contraceptive practices of the patient. With existing scientific evidence that improving the health of "W"omen will improve the health of mothers and children, we must focus on improving the health of "W"omen before pregnancy and put the "W" in Maternal and Child Health.

The clinical content of preconception care: infectious diseases in preconception care.

A number of infectious diseases should be considered for inclusion as part of clinical preconception care. Those infections strongly recommended for health promotion messages and risk assessment or for the initiation of interventions include Chlamydia infection, syphilis, and HIV. For selected populations, the inclusion of interventions for tuberculosis, gonorrheal infection, and herpes simplex virus are recommended. No clear evidence exists for the specific inclusion in preconception care of hepatitis C, toxoplasmosis, cytomegalovirus, listeriosis, malaria, periodontal disease, and bacterial vaginosis (in those with a previous preterm birth). Some infections that have important consequences during pregnancy, such as bacterial vaginosis (in those with no history of preterm birth), asymptomatic bacteriuria, parvovirus, and group B streptococcus infection, most likely would not be improved through intervention in the preconception time frame.

The clinical content of preconception care: reproductive history.

A history of previous birth of a low birthweight infant, previous cesarean sections, multiple previous spontaneous abortions, prior stillbirth, or uterine anomaly identifies women at increased risk for recurrent abortion, preterm birth, or stillbirth. We review the evidence for the potential benefit of reproductive history in identifying strategies for evaluation and treatment to prevent recurrent adverse pregnancy outcome. We offer evidence-based recommendations for management of women with these histories.

Maternal cigarette smoking, metabolic gene polymorphisms, and preterm delivery: new insights on GxE interactions and pathogenic pathways.

Preterm delivery (PTD, <37 weeks of gestation) is a significant clinical and public health problem. Previously, we reported that maternal smoking and metabolic gene polymorphisms of CYP1A1 MspI and GSTT1 synergistically increase the risk of low birth weight. This study investigates the relationship between maternal smoking and metabolic gene polymorphisms of CYP1A1 MspI and GSTT1 with preterm delivery (PTD) as a whole and preterm subgroups. This case-control study included 1,749 multi-ethnic mothers (571 with PTD and 1,178 controls) enrolled at Boston Medical Center. After adjusting covariates, regression analyses were performed to identify individual and joint associations of maternal smoking, two functional variants of CYP1A1 and GSTT1 with PTD. We observed a moderate effect of maternal smoking on PTD (OR = 1.6; 95% CI: 1.1-2.2). We found that compared to non-smoking mothers with low-risk genotypes, there was a significant joint association of maternal smoking, CYP1A1 (Aa/aa) and GSTT1 (absent) genotypes with gestational age (beta = -3.37; SE = 0.86; P = 9 x 10(-5)) and with PTD (OR = 5.8; 95% CI: 2.0-21.1), respectively. Such joint association was particularly strong in certain preterm subgroups, including spontaneous PTD (OR = 8.3; 95% CI: 2.7-30.6), PTD < 32 weeks (OR = 11.1; 95% CI: 2.9-47.7), and PTD accompanied by histologic chorioamnionitis (OR = 15.6; 95% CI: 4.1-76.7). Similar patterns were observed across ethnic groups. Taken together, maternal smoking significantly increased the risk of PTD among women with high-risk CYP1A1 and GSTT1 genotypes. Such joint associations were strongest among PTD accompanied by histologic chorioamnionitis.

A hospital-based doula program and childbirth outcomes in an urban, multicultural setting.

OBJECTIVES: The objective of this study is to determine whether there are differences in birth and breastfeeding outcomes for women who received labor support through a hospital-based doula program, compared with those who did not receive doula support in labor. METHODS: We conducted a retrospective program evaluation to compare differences in birth outcomes between births at 37 weeks or greater with doula support and births at 37 weeks or greater without doula support through the first seven years of a hospital-based doula support program. Log-binomial regression models were used to compare differences in cesarean delivery rates, epidural use, operative vaginal delivery, Apgar scores, breastfeeding intent and early breastfeeding initiation after controlling for demographic and medical risk factors. The propensity score was included as an additional covariate in our regression model to minimize issues of selection bias. Analyses were conducted for the whole cohort of 11,471 women and by parity and provider service in subgroup analyses. Cochran-Mantel-Haenszel test was performed to detect differences in effects over time. RESULTS: For the whole cohort, women with doula support had significantly higher rates of breastfeeding intent and early initiation. Subgroup analysis showed that having doula support was significantly related to: (a) higher rates of breastfeeding intent and early initiation rates for all women regardless of parity or provider with the exception of multiparous women with physician providers; (b) lower rates of cesarean deliveries for primiparous women with midwife providers. CONCLUSION: A hospital-based doula support program is strongly related to improved breastfeeding outcomes in an urban, multicultural setting.

Mifepristone in second-trimester medical abortion: a randomized controlled trial.

OBJECTIVE: To investigate the adjunctive use of mifepristone in second-trimester induction abortions using misoprostol 1 day after feticidal digoxin. METHODS: This is a randomized, placebo-controlled, double-blind trial of mifepristone in second-trimester induction termination using misoprostol after feticidal digoxin. Women seeking abortion between 18 and 23 weeks of gestation were offered enrollment. At the time of digoxin amnioinfusion, participants received a randomly allocated, identical-appearing capsule containing either mifepristone, 200 mg, or placebo. Patients returned the following day for induction with buccal misoprostol. The primary outcome was the time interval from the first misoprostol dose to abortion. Analysis utilized survival curves with log-rank testing. RESULTS: Of 64 women, 32 received mifepristone and 32 received placebo. The groups did not differ by ethnicity, age, parity, reason for termination, or gestational age. Median procedure time was significantly shorter for those who received mifepristone, 10 hours (95% confidence interval [CI] 8-12), than those who did not, 18 hours (95% CI 15-22), P<.01, and those parous, 10 hours (95% CI 9-14), compared with nulliparous, 16 hours (95% CI 12-22, P=.02). Other findings in the mifepristone compared with placebo group included rates of placental retention, 3.1% compared with 6.3% (P=.61), length of hospitalization, 0.66 days compared with 0.8 days (P=.23), and analgesic requirements, 27.2 mg compared with 39.3 mg morphine (P=.22). Side effects during induction were similar between groups. CONCLUSION: Addition of mifepristone in second-trimester termination inductions using misoprostol significantly reduces the abortion time interval. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, www.clinicaltrials.gov, NCT00382538 LEVEL OF EVIDENCE: I.

Impact of clinical and histologic correlates of maternal and fetal inflammatory response on gestational age in preterm births.

OBJECTIVE: To evaluate the impact of clinical and histopathologic correlates related to maternal and fetal inflammatory responses (MIR and FIR) on degree of preterm birth. METHODS: Pathology reports and clinical data from 577 singleton preterm births (<37 weeks of gestation) that took place between 1998 and 2004 were analyzed according to decreasing gestational age (>or=33 weeks, 29-32 weeks, and <29 weeks). MIR was defined by presence of subchorionitis, chorioamnionitis, deciduitis, or free membranitis; FIR was defined by presence of funisitis or chorionic plate vasculitis. The associations between MIR alone and MIR with FIR and gestational age subgroups were assessed using logistic regression. RESULTS: The presence of FIR in addition to MIR was more strongly associated with degree of prematurity than the presence of MIR alone, especially for those born at <29 weeks (OR=10.1 (95% CI 4.3-23.7) and OR=5.3 (95% CI 2.3-12.5), respectively). These associations remained significant after adjusting for maternal race, clinical signs of chorioamnionitis, medically indicated birth, and intrapartum corticosteroid, tocolysis and antibiotic use, and after stratification by clinical signs of chorioamnionitis and medically indicated birth. CONCLUSIONS: The combined presence of MIR and FIR is associated with a higher risk of extreme preterm birth (<29 weeks) than MIR alone, suggesting a contributory role of FIR in the pathophysiology of preterm birth.

Simultaneous very low dose mifepristone and vaginal misoprostol for medical abortion.

OBJECTIVE: This pilot study was designed to evaluate the outcome of medical abortion following simultaneous mifepristone (100 mg) and misoprostol (800 microg). METHODS: Enrollees had gestational ages up to 56 days and desired a medical abortion. They received 100 mg of mifepristone orally and 800 microg of misoprostol vaginally. Follow-up examination occurred in 2-7 days. A phone call 3 weeks later assessed symptoms and acceptability. A 95% success rate, as seen in higher dose studies, gives a 95% confidence interval of 88-100% for 40 subjects. RESULTS: Forty women were enrolled; 39 women had follow-up visits. Completed medical abortion was confirmed for 35 (90%) of 39 women. Four women had uterine aspiration. Two patients required repeat misoprostol. Median time from medication to abortion was 7 h. Most women (92%) strongly preferred taking all medications in the clinic. CONCLUSIONS: The simultaneous administration of vaginal misoprostol with 100 mg of oral mifepristone had the outcome of completed abortion within the predicted confidence interval. In addition, simultaneous dosing was highly acceptable.

Maternal hypertension as a risk factor for low birth weight infants: comparison of Haitian and African-American women.

BACKGROUND: The rate of low birth weight (LBW) of Black women is more than twice that of White women. This study explores if the rate of LBW differs between Haitian and African-American women with chronic hypertension. METHODS: A retrospective cohort study of all Black women self-identified as African-American (n = 12,258) or Haitian (n = 4320) delivering a singleton infant in Massachusetts between 1996 and 2000. RESULTS: Haitian women were more likely than African-American women to have chronic hypertension (2.7% vs. 2.1%, p = 0.006), but had similar rates of preeclampsia (3.1% vs. 3.3%, p = 0.27). The LBW rate was 10% among African-American women and 8.2% among Haitian women. After adjustment for sociodemographic, medical, and prenatal care characteristics, the greatest risks for delivering a LBW infant for Haitian women were chronic hypertension (OR = 6.8; 95% CI, 4.3, 10.6) and preeclampsia (OR = 3.2; 95% CI, 2.0, 5.1). For African-American women, the greatest risks for LBW infants were a history of delivering a LBW infant (OR = 3.9; 95% CI, 2.8, 5.4) and chronic hypertension (OR = 2.9; 95% CI, 2.1, 4.0). In a combined logistic regression model including interaction terms, chronic hypertension and preeclampsia continued to be associated with the greatest risk of LBW among all women. CONCLUSIONS: Differences in maternal risk factors and rates of LBW (8.2% vs. 10%) exist between Haitian and African-American women delivering infants in Massachusetts. While chronic hypertension and preeclampsia are strong risk factors for LBW for both Haitian and African-American women, unknown factors make these disorders much more potent for Haitian women.

A randomized clinical trial of the addition of laminaria to misoprostol and hypertonic saline for second-trimester induction abortion.

OBJECTIVE: To compare the outcomes of second-trimester induction abortion with misoprostol and hypertonic saline, with and without use of laminaria. METHOD: Fifty-eight women, between 17.5 and 22.5 weeks' gestation, were randomly assigned to receive or omit laminaria in conjunction with other procedures for induction abortion. All women received a fetocidal dose of 60 cc intra-amniotic hypertonic saline. If the woman was to receive laminaria, they were inserted next. This was followed by vaginal misoprostol 200 mug, which was repeated every 6 h. RESULT: Women with laminaria inserted before misoprostol administration had longer intervals from start of misoprostol to delivery of the fetus (induction times) than women without laminaria. Induction time was 14.4 vs. 11.4 h, respectively (p=.04, Wilcoxon rank sum test). Total misoprostol use was higher in the laminaria group, 628 mug (95% CI, 516-738) vs. 496 mug (95% CI, 419-573) (p=.05). Total analgesic use was also higher in the laminaria group, 41 mg of morphine (95% CI, 32-50) vs. 26 mg of morphine (95% CI, 18-32) (p=.02). CONCLUSION: Laminaria use, in conjunction with misoprostol and hypertonic saline, significantly prolongs induction time and increases narcotic analgesia usage.

Methods for induced abortion.

We describe present methods for induced abortion used in the United States. The most common procedure is first-trimester vacuum curettage. Analgesia is usually provided with a paracervical block and is not completely effective. Pretreatment with nonsteroidal analgesics and conscious sedation augment analgesia but only to a modest extent. Cervical dilation is accomplished with conventional tapered dilators, hygroscopic dilators, or misoprostol. Manual vacuum curettage is as safe and effective as the electric uterine aspirator for procedures through 10 weeks of gestation. Common complications and their management are presented. Early abortion with mifepristone/misoprostol combinations is replacing some surgical abortions. Two mifepristone/misoprostol regimens are used. The rare serious complications of medical abortion are described. Twelve percent of abortions are performed in the second trimester, the majority of these by dilation and evacuation (D&E) after laminaria dilation of the cervix. Uterine evacuation is accomplished with heavy ovum forceps augmented by 14-16 mm vacuum cannula systems. Cervical injection of dilute vasopressin reduces blood loss. Operative ultrasonography is reported to reduce perforation risk of D&E. Dilation and evacuation procedures have evolved to include intact D&E and combination methods for more advanced gestations. Vaginal misoprostol is as effective as dinoprostone for second-trimester labor-induction abortion and appears to be replacing older methods. Mifepristone/misoprostol combinations appear more effective than misoprostol alone. Uterine rupture has been reported in women with uterine scars with misoprostol abortion in the second trimester. Fetal intracardiac injection to reduce multiple pregnancies or selectively abort an anomalous twin is accepted therapy. Outcomes for the remaining pregnancy have improved with experience.

Bone metabolism and the perimenopause overview, risk factors, screening, and osteoporosis preventive measures.

In summary, FDA-approved therapies for prevention and treatment of osteoporosis are all antiresorptive agents. There are no approved therapies at this time that stimulate bone formation, although one such agent (PTH) is awaiting approval. Screening perimenopausal women at risk should identify osteopenic women early in the menopause before the accelerated bone loss of estrogen deficiency causes further irreversible erosion in bone density. The National Osteoporosis Foundation advocates initiating therapy to reduce fracture risk in postmenopausal women with T scores below -2 in the absence or factors and with T scores below -1.5 if other risk factors are present. Estrogen, alendronate, residronate, and raloxifene have all been shown to reduce the incidence of radiographic vertebral fractures in women at risk. Only alendronate and residronate have been shown in large randomized trials to reduce the incidence of nonvertebral fractures including hip fractures in women with postmenopausal osteoporosis. These antiresorptive therapies provide benefits above and beyond those of calcium and vitamin D alone. There is insufficient published evidence from randomized controlled trials convincingly to support a role for soy products, androgens, calcitonin, or fluoride in prevention of postmenopausal osteoporosis or reduction of fracture rates in women at risk.