J. Sheeder

Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference?

OBJECTIVE The purpose of this study was to determine contraceptive continuation and repeat pregnancy rates in adolescents who are offered immediate postpartum etonogestrel implant (IPI) insertion. STUDY DESIGN Participants in an adolescent prenatal-postnatal program were enrolled in a prospective observational study of IPI insertion (IPI group, 171) vs other methods (control group, 225). Contraceptive continuation and repeat pregnancies were determined. RESULTS Implant continuation at 6 months was 96.9% (156/161 participants); at 12 months, the continuation rate was 86.3% (132/153 participants). At 6 months, 9.9% of the control participants were pregnant (21/213); there were no IPI pregnancies. By 12 months, 18.6% of control participants (38/204) experienced pregnancy vs 2.6% of IPI recipients (4/153; relative risk, 5.0; 95% confidence interval [CI], 1.9-12.7). Repeat pregnancy at 12 months was predicted by not receiving IPI insertion (odds ratio, 8.0; 95% CI, 2.8-23.0) and having >1 child (odds ratio, 2.1; 95% CI, 1.1-4.3; P = .03). CONCLUSION IPI placement in adolescents has excellent continuation 1 year after delivery; rapid repeat pregnancy is significantly decreased compared with control participants.

Feasibility, effectiveness and safety of transvaginal digoxin administration prior to dilation and evacuation.

OBJECTIVES This study evaluates the feasibility, efficacy and safety of transvaginal digoxin administration to induce fetal demise prior to dilation and evacuation. STUDY DESIGN This descriptive report from a single center involves a large case series of dilations and evacuations (D&Es) ranging from 18 to 22 weeks of gestation. Transvaginal feticidal injection with digoxin was attempted in 1640 cases; intrafetal, intraamniotic and combined (intrafetal and intraamniotic) injections were administered. Digoxin dosage ranged from 0.5 to 3.0 mg, with the majority receiving 1.0 mg. Cases were reviewed to determine feasibility, efficacy and adverse events. RESULTS Successful completion of transvaginal injection occurred in 98.5% (1637/1662) of eligible cases, and 1596 cases were evaluable for fetal demise. Demise occurred by the time of D&E in 99.4% of all cases; 99.7% of intrafetal injections resulted in fetal demise. Doses ≥1 mg were equally effective (98.1%-99.6%) regardless of injection site (intraamniotic, combined intrafetal/intraamniotic or intrafetal). Doses <1.0 mg were less successful at inducing demise if not administered intrafetally (p<.001). Rates of ruptured membranes (4.1%), chorioamnionitis (0.49%) and extramural deliveries (0.12%) were low. Patients who experienced complications were more likely to be of greater gestational age and have had a previous cesarean section. CONCLUSIONS Transvaginal digoxin administration is feasible, effective and safe. IMPLICATION STATEMENT This study demonstrates the feasibility, effectiveness and safety of transvaginal digoxin administration in a large clinical cohort. Future studies will be needed to determine if this method of administration improves patient satisfaction and outcomes when compared to transabdominal feticidal injections.

Original research articleUmbilical cord transection to induce fetal demise prior to second-trimester D&E abortion☆

OBJECTIVE Induction of fetal demise via transabdominal injection has been used to facilitate second-trimester abortion but requires a second procedure and has associated risks. The method of amniotomy, cord transection and documentation of fetal asystole immediately prior to dilation and evacuation (D&E) is an alternative approach; however, characteristics of this method have not been described. STUDY DESIGN This descriptive report from a single center involves a large case series of D&Es ranging from 16 to 23 weeks of gestation. Umbilical cord transection (UCT) was attempted immediately prior to D&E in 407 cases, which were reviewed to determine success, time to fetal asystole and complications. RESULTS Both UCT and asystole were achieved in 100% of cases. Mean time from UCT to asystole was 3.35±2.11 min. When compared to cases performed at less than 20 weeks of gestation, mean time to asystole was slightly longer in the ≥20-week group (3.7±2.4 min vs. 3.1±1.9 min; p=.008). Few patients had minor (4.6%) or major (0.3%) complications; time to asystole was not associated with complications. CONCLUSIONS Umbilical cord transection immediately prior to D&E is a feasible, efficacious and safe way to induce fetal demise without performing additional procedures. IMPLICATION STATEMENT This study demonstrates the feasibility, effectiveness and safety of utilizing umbilical cord transection to induce fetal demise in a large cohort. This method is an alternative to other feticidal procedures.

Longitudinal follow up of dysglycemia in overweight and obese pediatric patients

To examine factors related to progression of dysglycemia in overweight and obese youth in a large primary care setting.

Risk of hemorrhage during dilation and evacuation for second-trimester intrauterine fetal demise

• Hemorrhage associated with secondtrimester D&E is uncommon • Fetal demise of <5 weeks’ duration and <21 weeks GA have no greater risk of hemorrhage than D&Es performed for other indications • Inpatient management may be appropriate for cases ≥21 weeks or with prolonged demise • Pre-procedure labs did not predict hemorrhage • Retrospective case control study at an urban university hospital • All D&Es at ≥12 weeks performed from 12/2005-5/2013 were reviewed • D&Es performed for IUFDs were compared to those for other indications (controls) • Gestational age (GA) defined by ultrasound measurements at time of D&E • Exclusion criteria: inherited coagulopathies, failed induction of labor, pre-procedure sepsis, incomplete medical records • Outcome variables included EBL, D&E complications, post-procedure coagulopathy • Hemorrhage defined as EBL >500 mL REFERENCES