Jennefer A. Russo

Transvaginal administration of intraamniotic digoxin prior to dilation and evacuation

BACKGROUND Transabdominal injection of digoxin into the amniotic fluid or fetus to induce fetal demise before dilation and evacuation (D&E) abortion has become common practice since the passage of the Partial-Birth Abortion Ban Act in 2007. STUDY DESIGN We performed a prospective study to assess the feasibility of transvaginal administration of intraamniotic digoxin the day before D&E. All women between 18 0/7 and 23 5/7 weeks of gestation seeking termination from December 2009 to May 2011 were approached for study participation. Women who declined participation were asked to identify their primary rationale. For women declining study participation, transection of the umbilical cord during D&E was performed to meet the requirements of the ban. RESULTS Over 18 months, 134 women met study entry criteria and 108 (81%) declined to participate. Of the 26 women who enrolled, 1.0 mg undiluted digoxin was successfully administered transvaginally in 24 (92%, 95% confidence interval 75%-99%). The most common reasons for declining participation were discomfort with preoperatively inducing fetal demise (37%) and desire to avoid a medically unnecessary medication (36%). CONCLUSIONS Transvaginal administration of digoxin is a feasible alternative to transabdominal administration to induce preoperative fetal demise. The majority of women decline digoxin administration when an alternative is available.

Antiabortion violence in the United States

BACKGROUND This study was conducted to determine if an association exists between the amount of harassment and violence directed against abortion providers and the restrictiveness of state laws relating to family planning. STUDY DESIGN We used responses from a July 2010 survey of 357 abortion providers in 50 states to determine their experience of antiabortion harassment and violence. Their responses were grouped and analyzed in relation to a published grading of state laws in the United States (A, B, C, D and F) as they relate to restrictions on family planning services. RESULTS Group by group comparison of respondents illustrates that the difference in the number of reported incidents of minor vandalism by group is statistically significant (A vs. C, p=.07; A vs. D, p=.017; A vs. F, p=.0002). Incidents of harassment follow a similar pattern. There were no differences noted overall for violence or major vandalism. Major violence, including eight murders, is a new occurrence in the last two decades. CONCLUSIONS Harassment of abortion providers in the United States has an association with the restrictiveness of state abortion laws. In the last two decades, murder of abortion providers has become an unfortunate part of the violence.

Controversies in family planning: retained products of conception

In July 2011 the authors performed a literature review to develop a protocol for the management of retained products of conception (RPOC) after medical and surgical abortion. The protocol is to be used by a legal abortion provider in Bogota Colombia. The report answers questions about the incidence of RPOC in medical and surgical abortion its risk factors and specific diagnostic criteria. Furthermore the report discusses the use of antibiotics and treatment of RPOC with misoprostol the incidence of a paracervical block and the relationship between cannula size and safety of aspiration procedures. Copyright

Controversies in family planning: arteriovenous malformation

JG is a 25-year-old G2P0 female with one previous uneventful medical abortion in October 2008 and no live children. In December 2009, she was admitted to a hospital with a first episode of severe vaginal bleeding. An arteriovenous malformation (AVM) was suspected on a vaginal ultrasound and was confirmed by Doppler ultrasound and an MRI. These studies demonstrated a dilated vessel arising from the left uterine artery, reaching almost to the endometrial surface and ending as a cystic 15-mm formation with demonstrable internal flow (Figs. 1, 2 and 3). The hemorrhage stopped spontaneously and no treatment was initiated. She had a second episode of bleeding in April which again stopped by itself. No transfusions were needed but her hemoglobin dropped to 9 mg/mL each time. Apart from these two episodes, her menses remained regular and normal in quantity. In July 2010, a uterine artery embolization was unsuccessfully attempted, likely due to thrombosis of the lesion (in spite of multiple injections of contrast media, no flow was demonstrated at the site of the lesion and therefore the malformation could not be visualized nor embolized) and an open (wedge) resection was recommended. JG presented in November 2010 with an undesired 8week pregnancy to Orientame, a private nonprofit clinic in Bogota, Colombia. She had not had any bleeding. Given her history of AVM, we were to proceed with abortion for the indication of threat to the health of the patient. In Colombia, this is a legal indication for abortion. Although the law in Colombia states that abortion is legal for the protection of a womans health, many hospitals delay

Women's information-seeking behavior after receiving contraceptive versus noncontraceptive prescriptions

BACKGROUND Contraceptives are among the most commonly prescribed medications used by women of reproductive age, but little is known about womens information-seeking behavior after receiving prescriptions for medication. STUDY DESIGN All reproductive-age women who visited one of four primary care clinics in Western Pennsylvania between October 2008 and April 2010 were invited to complete a follow-up survey after their visit which included questions regarding medications prescribed, information-seeking after their visit and their perceptions of the quality of the information they found. RESULTS Of the 218 women prescribed contraceptives, 49% sought additional information after their visit. In models adjusted for sociodemographic and reproductive characteristics of the respondents, women who received a contraceptive prescription were twice as likely to seek additional information about their medication as women who received noncontraceptive prescriptions [odds ratio (OR)=2.06, 95% confidence interval (CI) 1.47-2.90]. Women who received a contraceptive prescription were more likely to seek information from the Internet (OR=1.84, 95% CI 1.26-2.70) and from the package insert (OR=1.55, 95% CI 1.02-2.36) than women who received noncontraceptive prescriptions. CONCLUSIONS Women frequently sought additional information on contraceptive prescriptions. Efforts are needed to increase the quantity and improve the quality of contraceptive counseling provided by primary care providers and the quality of the information provided by package inserts and the Internet.

Contraception for Women with Medical Conditions

Pregnancy represents a higher risk state than the nonpregnant condition for all women, but especially for women with medical conditions. Any choice of contraceptive for a patient with a medical condition should include a weighing of the risks of that method with the risk of pregnancy. This chapter will outline resources for clinicians attempting to determine the best contraceptive method for women with medical conditions, specific behaviors, or attributes, including the Centers for Disease Control US Medical Eligibility Criteria for Contraceptive Use and Selected Practice Recommendations.

Controversies in family planning: postabortal pelvic inflammatory disease.

In July 2011, we performed a review of the literature to develop a protocol for the management of infection after medical and surgical abortion. The protocol is to be used by a legal abortion provider in Bogota, Colombia. The questions we sought to answer were the following: How is postabortal infection defined and diagnosed? Is there a clinical distinction between endometritis, salpingitis, and parametritis? What is the incidence of postabortal infection? What are risk factors for postabortal infection? What are the most common microorganisms involved in postabortal infection? What are the sensitivity, specificity and predictive values for each test used in the diagnosis of postabortal infection? Is there a need to order these tests? What is the best antibiotic treatment regimen for postabortal infection? Are there long-term sequelae associated with postabortal infection? If so, what are they? Should the partner of the patient with a postabortal infection be treated?