Inequities in Adverse Maternal and Perinatal Outcomes: The Effect of Maternal Race and Nativity.

OBJECTIVES: To evaluate the effect of race and ethnicity on differences in maternal and perinatal outcomes among U.S.-born and foreign-born women, as well as racial and ethnic disparities in outcomes within these groups. METHODS: This retrospective study analyzed singleton pregnancies (n = 11,518) among women delivering at Boston Medical Center from January 2010-March 2015. Outcomes of interest included preterm birth, early preterm birth, cesarean delivery, hypertensive disorders, diabetes, low birth weight at term (LBW, < 2500 g), NICU admission and intrauterine fetal demise (IUFD). Prevalence ratios and 95% confidence intervals comparing outcomes between U.S.- and foreign-born women were calculated and stratified by race. Obstetric outcomes among Black and Hispanic women were compared to those of white women within both U.S.- and foreign-born groups. RESULTS: Preterm birth, hypertensive disorders, LBW and NICU admission were more likely to occur among U.S.-born women and their neonates compared to foreign-born women. Controlling for sociodemographic characteristics did not significantly impact these disparities. Among foreign-born women, Black women had a higher prevalence of many maternal and neonatal complications, while Hispanic women had a lower prevalence of some complications compared to white women. Black woman and infants consistently exhibit worse outcomes regardless of their nativity, while Hispanic women foreign-born women experience less disparate outcomes. CONCLUSIONS FOR PRACTICE: Overall, women born in the United States are at higher risk of several adverse perinatal outcomes compared to foreign-born women. Racial and ethnic disparities in birth outcomes exist in both groups. However, the complex interplay between biopsychosocial influences that mediate these inequities appear to have different effects among U.S- and foreign- born women. A better understanding of these factors can be used to combat disparities and improve outcomes for all women.

Perceived barriers to Chagas disease screening among a diverse group of prenatal care providers.

BACKGROUND: Chagas disease is a vector borne infection of poverty endemic to Latin America which affects an estimated 40,000 women of child-bearing age in the United States (US). In the US Chagas disease is concentrated among individuals who have lived in endemic areas. Prenatal diagnosis and treatment are needed to prevent congenital transmission. The objective of this study was to assess perceived barriers to Chagas disease screening among prenatal care providers in Obstetrics/Gynecology and Family Medicine Departments of a tertiary care safety-net hospital caring for a significant at-risk population. METHODOLOGY/PRINCIPAL FINDINGS: An anonymous survey was distributed to 178 Obstetrics/Gynecology and Family Medicine practitioners. Of the 66 respondents, 39% thought Chagas screening was very important, and 48% somewhat important as a public health initiative. One third judged screening patients during clinic visits as very important. Most respondents (64%) reported being familiar with Chagas disease. However, only 32% knew how to order a test and only 22% reported knowing what to do if a test was positive. CONCLUSIONS/SIGNIFICANCE: These findings will be incorporated into measures to facilitate full implementation of Chagas screening, and can inform initiatives at other centers who wish to address this deeply neglected infection among their patient families. Greater integration of information on Chagas disease screening and treatment in medical and nursing education curricula can contribute to addressing this disease with the focus that its potentially fatal sequelae merit.

Chlamydia trachomatis Infection, when Treated during Pregnancy, Is Not Associated with Preterm Birth in an Urban Safety-Net Hospital.

Preterm birth is a major public health problem, occurring in more than half a million births per year in the United States. A number of maternal conditions have been recognized as risk factors for preterm birth, but for the majority of cases, the etiology is not completely understood. Chlamydia trachomatis is one of the most prevalent sexually transmitted infections in the world. However, its role in adverse pregnancy outcome in women is still debated. In order to determine if genitourinary tract infection with C. trachomatis during pregnancy was associated with preterm birth, we conducted a case-control study on women who delivered at Boston Medical Center, an urban "safety-net" hospital that serves a socioeconomically disadvantaged and racially diverse population. Women with known risk factors for preterm birth or immune suppression were excluded. Variables collected on enrolled subjects included demographics; diagnosis of C. trachomatis during or prior to pregnancy; tobacco, alcohol, and illicit substance use; gestational age; and birthweight and gender of the newborn. We also collected urine for chlamydia testing at the time of delivery and placental biopsies for nucleic acid amplification and histological studies. A total of 305 subjects were enrolled: 100 who delivered preterm and 205 who delivered full term. Among those subjects, we identified 19 cases of pregnancy-associated C. trachomatis infection: 6/100 preterm and 13/205 full term, a difference which was not statistically significant. Only two cases of untreated chlamydia infection were identified postpartum, and both occurred in women who delivered at term. We conclude that genitourinary tract infection with C. trachomatis during pregnancy, when appropriately treated, is not associated with preterm birth.

Effect of pregnancy on uterine-sparing pelvic organ prolapse repair.

INTRODUCTION AND HYPOTHESIS: The impact of pregnancy on pelvic organ prolapse following surgical repair is not well understood. We describe five cases of pregnancy following uterine-sparing surgical treatment of pelvic organ prolapse. We analyzed the changes in women's Pelvic Organ Prolapse Quantification (POP-Q) scores. We hypothesized there would be significant improvement in anterior and apical prolapse after surgery and no recurrence of prolapse after pregnancy. METHODS: We performed a retrospective review of the electronic medical record for cases of uterine-sparing apical suspension performed between January 2004 and December 2012 at Boston Medical Center. Student's t-test for paired design was used to compare the change in POP-Q score at points Aa, Ba and C obtained at preoperative, postoperative and postpartum visits. RESULTS: Subjects in our series demonstrated significant improvement in their prolapse at all POP-Q points of interest between the pre- and postoperative visits, particularly at point C. There was a slight increase in POP-Q score from the postoperative visit to the postpartum visit, but this change was not statistically significant. CONCLUSIONS: Our findings are consistent with previous literature, suggesting that the results of uterine-sparing apical prolapse repair are maintained after pregnancy. Women may be counseled to consider surgical prolapse repair even if they have not completed childbearing.

Mifepristone and misoprostol compared to osmotic dilators for cervical preparation prior to surgical abortion at 15-18 weeks' gestation: a randomised controlled non-inferiority trial.

OBJECTIVE: Cervical preparation is recommended prior to second-trimester surgical abortion. Osmotic dilators are an effective means to prepare the cervix, but require an additional procedure and may cause discomfort. We compared cervical preparation with mifepristone and misoprostol to preparation with osmotic dilators. STUDY DESIGN: A randomised, controlled, non-inferiority trial was performed to compare cervical preparation with mifepristone and misoprostol to preparation with osmotic dilators in women undergoing surgical abortion between 15 and 18 weeks gestation. The medication group (n=29) received mifepristone 200 mg orally 24 hours prior to uterine evacuation and misoprostol 400 µg buccally 2 hours before the procedure. The dilator group (n=20) underwent osmotic dilator insertion 24 hours prior to the procedure. The primary outcome was total procedure time, from insertion to removal of the speculum. Secondary outcomes included operative time (from intrauterine instrumentation to speculum removal), initial cervical dilation, nausea, pain, ease of procedure, and whether participants would choose the same modality in the future. RESULTS: For mean total procedure time, medication preparation (14.0 min, 95% CI 12.0-16.1) was not inferior to dilators (14.3 min, 95% CI 11.7 to 16.8, p<0.001). Mean operative time and ease of procedure were also similar between groups. More women in the medication group than the dilator group would prefer to use the same method in the future (86% vs 30%, p=0.003). CONCLUSION: Prior to surgical abortion at 15-18 weeks, use of mifepristone and misoprostol did not result in longer procedure times than overnight osmotic dilators. TRIAL REGISTRATION NUMBER: NCT01462.

Surgical Anatomy of Vaginal Hysterectomy-Impact of a Resident-Constructed Simulation Model.

OBJECTIVES: Obstetrics and gynecology residents are less prepared to perform vaginal hysterectomy (VH), despite its advantages over other hysterectomy routes. The American Congress of Obstetricians and Gynecologists and Council on Resident Education in Obstetrics and Gynecology have prioritized simulation training in VH. Our objective was to improve residents' understanding of surgical anatomy of VH using a resident-constructed, low-cost, low-fidelity model. METHODS: A single simulation session was held in November 2016. Residents constructed a pelvic model, guided by 2 surgeons. A pretest and a posttest were administered. Experienced-based responses were tabulated for frequencies and contents. Improvement on knowledge-based questions was assessed using McNemar's test. RESULTS: Of 20 residents, 16 completed the pretest and 14 (70%) completed pretests and posttests. One hundred percent of postgraduate year (PGY)-4 had performed greater than 10 VH (11-21) and 75% of PGY-3 had performed 5 to 12 VH. Although 75% of PGY-3 and 100% of PGY-4 felt comfortable performing VH, baseline knowledge of essential surgical anatomy of VH was low (65.8%). The PGY-3 and -4 group (n=8) experienced a mean improvement of 24.4% (mean pretest score 65.8% vs mean posttest score 90%; 95% confidence interval, +14.1% to +33.3%, P=0.0005). The PGY-1 and -2 groups (n=6) experienced a mean improvement of 43.3% (mean pretest score, 41.7% vs mean posttest score, 85%; 95% confidence interval, +26.7% to +59.2%, P=0.001). After the session, all residents reported improved understanding surgical anatomy of VH and "more hands-on sessions" was the most frequently requested teaching aid. CONCLUSIONS: Residents desire additional model-based simulation training in VH, and such structured, model-based simulations can identify and address gaps in resident knowledge of surgical anatomy of this important operation.

Human Papillomavirus Co-Testing Results Effectively Triage Normal Cervical Cytology in HIV-Positive Women Aged 30 Years and Older.

OBJECTIVE: The aim of the study was to assess whether HIV-positive (HIV+) women aged 30 years and older with concurrent normal cervical cytology and undetectable cervical HPV have a low 3-year risk of developing cervical intraepithelial neoplasia grade 2 or higher (CIN 2+) in a clinical setting. MATERIALS AND METHODS: We conducted a retrospective chart review of HIV+ women aged 30 years and older at a single institution with normal cervical cytology and concurrent human papillomavirus (HPV) testing between November 2008 and December 2010. The participants were stratified by initial HPV testing results and followed to either the study end point (CIN 2+) or until the last cervical cytology or colposcopy before January 2015. Kaplan-Meier survival curves were used to analyze CIN 2+ diagnosis for follow-up with log-rank testing of the null hypothesis. Cox proportional hazard regression was performed to calculate crude and adjusted hazard ratios controlling for ethnicity and CD4 levels. RESULTS: We identified 325 HIV+ women with normal cytology and follow-up; 66 (20%) of these women had detectable HPV. The cumulative diagnosis of CIN 2+ at 4 years was significantly lower in the HPV-negative cohort compared with the HPV-positive cohort (1.4%, 95% CI = 0.3%-4.6% vs 14.5%, 95% CI = 5.8%-27.1%), respectively; the median duration to CIN 2+ diagnosis was longer in the HPV-negative cohort compared with the HPV-positive cohort (4.2 years vs 1.5 years, respectively, p < .02). CONCLUSIONS: HIV+ women aged 30 years and older with concurrent normal cervical cytology and undetectable cervical HPV have a low 3-year risk of subsequent diagnosis of CIN 2+. The study validates the recently updated US recommendations for the use of co-testing in screening HIV+ women.

Tuboovarian abscess. Factors associated with operative intervention after failed antibiotic therapy.

OBJECTIVE: To evaluate whether size of tuboovarian abscess (TOA) and other clinical characteristics were associated with the need for surgical intervention. STUDY DESIGN: A retrospective chart review of patients hospitalized at an inner city hospital between January 1998 and December 2007 with the diagnosis of TOA. Demographics, medical history, clinical markers of infection, radiology, pathology, and operative reports were examined. Student's t test and Fisher's exact test were utilized to analyze differences between groups. Multiple logistic regression analysis was performed to identify significant predictors of surgery. Receiver operating characteristic (ROC) analysis was used to assess how well TOA size and other significant variables were associated with the need for operative or procedural intervention. RESULTS: A total of 163 patients with TOA were identified; 41 patients were excluded based on specific criteria. Of the remaining 122 women, 65.6% responded to antibiotic therapy, and 34.4% had surgery or ultrasound-guided drainage. Mean TOA size in the medical group was 4.4 cm as compared to 7.3 cm in the surgical group (p < 0.0001). Maximal leukocyte count, older age, and parity were associated with significantly higher risk of surgery. The significant univariate variables remained significant after multivariate analysis. ROC curve analysis revealed an excellent discrimination of the need for surgical treatment as predicted by TOA size, with increased likelihood of surgical or procedural intervention with increasing TOA size. CONCLUSION: Radiographic size, leukocyte count, age, and parity are associated with operative or procedural treatment of tuboovarian abscess.

Mifepristone vs. osmotic dilator insertion for cervical preparation prior to surgical abortion at 14-16 weeks: a randomized trial.

BACKGROUND: Cervical preparation is recommended before second-trimester abortion. We investigated the use of a pharmacologic method of preparation, mifepristone, as compared to osmotic dilators for surgical abortions at 14-16 weeks. STUDY DESIGN: This was a randomized, parallel-group study with concealed allocation. Women were allocated to receive osmotic dilators or mifepristone 200 mg orally 24 h prior to abortion. The study population was 50 women seeking surgical abortion at 14-16 menstrual weeks in a hospital-based abortion service. The primary outcome was the length of time to perform the procedure; the study had 80% power to detect a difference of more than 3 min in procedure time. Secondary outcomes included cervical dilation, side effects and acceptability. RESULTS: The mean abortion time for the osmotic dilator group was 8.00 min [95% confidence interval (CI) 6.75-11.47], and that for the mifepristone group was 9.87 min (95% CI 8.93-11.36). Side effects of pain were more common in the osmotic dilator group. CONCLUSION: Mifepristone did not increase the time for abortion by more than the prespecified margin (3 min). Women preferred mifepristone to osmotic dilators.

Minimally abnormal Pap testing and cervical histology in HIV-infected women.

OBJECTIVE: To assess the underlying histology of HIV-infected women with minimally abnormal Pap tests compared to HIV-uninfected women by evaluating their colposcopic and histologic outcomes. METHODS: Retrospective analysis was performed to identify HIV-infected women who had at least one cervical Pap test from 2002 through 2008 at Boston Medical Center. We identified women who underwent colposcopy within 6 months of a minimally abnormal Pap test (atypical squamous cells of undetermined significance with positive high-risk human papillomavirus testing [ASCUS/HPV+] or low-grade squamous intraepithelial lesion (LSIL)). Our outcome was the proportion of HIV-infected women with histologic cervical intraepithelial neoplasia 2 or worse (CIN2+). We then compared these outcomes to those of a cohort of HIV-uninfected women from the same institution. RESULTS: There were 655 HIV-infected women who had Pap testing in the study time frame, and 146 (22%) had a minimally abnormal Pap test (ASCUS/HPV+ or LSIL). Of the 90 HIV-infected women who had subsequent colposcopy within 6 months, colposcopy was negative for 20 (22%), CIN1 for 41 (46%), and CIN2+ for the remaining 29 (32%). During the same time period, there were 747 HIV-uninfected women who underwent colposcopy within 6 months of a minimally abnormal Pap test. Colposcopy was negative for 336 (45%), CIN1 for 254 (34%), and CIN2+ for 157 (21%). After adjusting for differences in age and race, the HIV-infected women were more likely to have CIN2+ after a minimally abnormal Pap test (p=0.002) (adjusted odds ratio [OR] 2.17, 95% confidence interval [CI] 1.33-3.62). There were no diagnosed cases of cervical cancer. CONCLUSIONS: HIV-infected women have higher rates of underlying CIN2+ for minimally abnormal Pap tests compared with HIV-uninfected women.

Somali immigrant women's perceptions of cesarean delivery and patient-provider communication surrounding female circumcision and childbirth in the USA.

OBJECTIVE: To explore perceptions of cesarean delivery and patient-provider communication surrounding female circumcision and childbirth through interviews with Somali women residing in the USA. METHODS: Semistructured in-depth interviews were conducted with 23 Somali immigrant women living in Boston who had given birth in the USA and Africa. Interviews asked about birth experiences in the USA and Africa, as well as norms and attitudes surrounding childbirth practices. Interview transcripts were coded and themes identified through an iterative process. RESULTS: Participants were aged 25-52 years and had been living in the USA for an average of 7 years. All women had experienced circumcision. Five women had undergone a cesarean delivery. Women feared having a cesarean because of their perception that it could result in death or disability. Women also highlighted that providers in the USA rarely discussed female circumcision or how it could affect childbirth experiences. CONCLUSIONS: Previous experiences and cultural beliefs can affect how Somali immigrant women understand labor and delivery practices in the USA and can explain why some women are wary of cesarean delivery. Educating providers and encouraging patient-provider communication about cesarean delivery and female circumcision can ease fears, increase trust, and improve birth experiences for Somali immigrant women in the USA.

Effect of patient age on outcomes and compliance in women with minimally abnormal pap tests.

OBJECTIVE: To assess follow-up and histologic outcomes by age for an indigent urban cohort of women with minimally abnormal cytology. STUDY DESIGN: Retrospective analysis of Pap tests was performed (January 2, 2002, to June 30, 2005). Adolescents (age < 21) and women with atypical squamous cells of undetermined significance (ASCUS)/high-risk human papillomavirus (HPV) and low-grade squamous intraepithelial lesions (LSIL) Pap results were studied and followed for outcomes at 2 years. The chi2 test was performed to evaluate differences among groups; statistical significance was established as p < or = 0.05. RESULTS: A total of 2,266 women were studied--676 adolescents, 1,063 women aged 21-30 years, and 527 women > 30 years of age. Results included 619 ASCUS/ high-risk HPV and 1,647 LSIL results. Compliance was similar across age-groups; 31% never returned for follow-up. CIN2 was detected in 18.8% of adolescents, 21.6% of women aged 21-30, and 15.7% of women > 30 years (p = 0.53). CIN3 was detected in 8.5% of adolescents, 8.1% of women aged 21-30, and 7.7% of women > 30 years (p = 0.55). CONCLUSION: Adolescents and women had similar rates of loss to follow-up after having a minimally abnormal Pap test. The likelihood of detecting CIN2-3 was similar regardless of age.

Abnormal anal cytology in HIV-infected women.

OBJECTIVE: The purpose of this study was to assess the prevalence of and risk factors for abnormal anal cytology and human papillomavirus (HPV) infections in women who are human immunodeficiency virus (HIV) positive. STUDY DESIGN: We conducted an observational single center study of 100 HIV-infected women with cervical and anal specimens that were obtained for cytologic and high-risk HPV testing with Hybrid Capture 2. RESULTS: Seventeen women had abnormal anal cytology; 16 women had anal HPV; 21 women had abnormal cervical cytology, and 24 women had cervical HPV. Abnormal anal cytology was associated with cervical HPV infection, abnormal cervical cytology, and anal HPV infection in univariate analysis. In multivariate analysis, abnormal anal cytology was associated with a CD4 count <200 cells/mm(3), a history of sexually transmitted disease, and concurrent cervical cytologic abnormality. CONCLUSION: HIV-infected women are at high risk for abnormal cytology and HPV infections of both the anus and cervix. Risk factors for abnormal anal cytology include abnormal cervical cytology, cervical and anal HPV infections, and low CD4 count.

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.

Intervention rates for placental removal following induction abortion with misoprostol.

BACKGROUND: Second-trimester terminations can be performed via surgical or medical methods. It is essential to have the ability to safely and effectively perform induction terminations to offer a full range of services. Many studies of induction abortions report routine operative removal of the placenta after a set time period resulting in high rates of operative procedures. STUDY DESIGN: A retrospective chart review was performed for 233 women who underwent second-trimester induction abortions between November 2003 and November 2006. All women received intraamniotic injection of digoxin for feticide 1 day prior to induction. All inductions were performed using a schedule of 400 mcg of misoprostol initially followed by 200 mcg every 6 h for a maximum of 48 h. There were three methods of administering misoprostol: (1) vaginal administration for all doses, (2) vaginal and buccal used in combination and (3) buccal for all doses. Spontaneous expulsion of the placenta was expected. Operative intervention was performed for excessive bleeding or to expedite hospital discharge after a minimum of 4 h. No manual removal of placenta was done. RESULTS: The rate of operative intervention for retained placentas was 6% (14/233). Most (11/14) of the patients who underwent operative extraction for retained placentas did so to expedite discharge from the hospital. Overall, expectant management to allow spontaneous expulsion of the placenta for at least 4 h was not associated with serious morbidity. CONCLUSIONS: Our regimen of digoxin and misoprostol with a policy of expectant management of placental passage is associated with a very low rate of instrumented removal of the placenta. In the absence of bleeding, patients may be afforded intervals to at least 4 h for spontaneous expulsion of the placenta after fetal expulsion.

Bleeding after medication-induced termination of pregnancy with two dosing schedules of mifepristone and misoprostol.

OBJECTIVE: This study examines bleeding pattern following medication-induced termination of pregnancy, comparing two different dosing schedules of mifepristone and misoprostol. STUDY DESIGN: Diary information was analyzed from a randomized, multicenter trial in which women used vaginal misoprostol 800 mug either 6-8 or 24 h following 200 mg of oral mifepristone. PARTICIPANTS AND METHODS: One thousand eighty women with pregnancies up to 63 days' gestation were recruited for the study; 540 were randomized to the 6- to 8-h dosing schedule, and 540 were randomized to the 24-h dosing schedule. Subjects recorded daily bleeding in a diary over 5 weeks. RESULTS: Total duration of bleeding ranged from 1 to 54 days, with a median of 7 days. Duration of spotting ranged from 1 to 80 days, with a median of 5 and 6 days (NS) in each of the two groups. Neither duration of bleeding nor duration of spotting were related to interval between mifepristone and misoprostol. Bleeding and spotting durations were not correlated with maternal age or smoking. Increased gestational age was correlated with longer bleeding and spotting times. Nulliparity was associated with longer bleeding time. CONCLUSION: Varying the interval between mifepristone and misoprostol in medication abortion does not affect duration or quantity of bleeding.

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.

Misoprostol as the primary agent for medical abortion in a low-income urban setting.

The purpose of this study was to assess the outcomes of early medical abortion in an inner-city hospital abortion service, using misoprostol as the primary agent. This was a retrospective chart review from July 2001 through December 2002. Women were eligible if they had a viable pregnancy with gestational age 8 weeks or less by transvaginal ultrasound and no medical contraindications. Two doses of 800 microg misoprostol were administered vaginally, 24 h apart. Initial follow-up was scheduled 2-3 days later. Of the 440 women who underwent medical abortion, 373 (90.8%, 95% confidence interval (CI) 88-94%) completed abortion medically, 38 (9.2%) had uterine aspiration and the remainder had incomplete or no follow-up. Of uterine aspirations, 11 were medically indicated, giving a rate of indicated aspiration of 2.7%. Gestational age, age, gravidity, parity, past abortion history, ethnic group and payer did not significantly correlate with overall rate of aspiration or rate of follow-up, but gestational age was correlated with medically indicated aspiration. Among 57 women who reported a time of tissue passage, the mean time from initial misoprostol dose was 8.5 h (95% CI 6.5-13 h).