Jennifer L. Kerns

Quick Start: a novel oral contraceptive initiation method.

Conventional oral contraceptive (OC) starting instructions require waiting until menses to begin the OC. The conventional approach requires detailed patient education about when to begin and also may require the use of less effective or less acceptable interim contraceptive protection until menses. At our urban family planning clinic, we routinely offer patients starting the OC the option of taking the first tablet sooner. We prospectively evaluated predictors of short-term OC continuation among 250 OC requestors who were offered several approaches to OC initiation. Telephone follow-up of 91% of participants showed that women who swallowed the first OC in the clinic were more likely to continue the OC until the second package than women who planned to start the OC later (adjusted OR 2.8, 95% C.I. 1.1-7.3). Other factors associated with short-term continuation were: partners knowledge of planned OC use, older age, and participants agreement that she would be very unhappy about becoming pregnant in the next 6 months.

Management of postabortion hemorrhage

Hemorrhage after abortion is rare, occurring in fewer than 1% of abortions, but associated morbidity may be significant. Hemorrhage can be caused by atony, coagulopathy and abnormal placentation, as well as by such procedure complications as perforation, cervical laceration and retained tissue. Evidence on which to make recommendations regarding risk factors and treatment for postabortion hemorrhage is extremely limited. Although medical abortion is associated with more bleeding than surgical abortion, overall bleeding for the two methods is minimal and not clinically different. Identifying patients who may be at increased risk of hemorrhage can help reduce blood loss with abortion. Specifically, women with a uterine scar and complete placenta previa seeking abortion at gestations greater than 16 weeks should be evaluated for placenta accreta. For women at high risk of hemorrhage, referral to a high-acuity center should be considered. We propose an algorithm for treating postabortion hemorrhage as follows: (1) assessment and exam, (2) massage and medical therapy, (3) resuscitative measures with laboratory evaluation and possible re-aspiration or balloon tamponade, and (4) interventions such as embolization and surgery. The Society of Family Planning recommends preoperative identification of women at high risk of hemorrhage as well as development of an organized approach to treatment. Further studies are needed on prophylactic use of uterotonic medication, intraoperative ultrasound and optimal delivery of the placenta after second-trimester medical abortion.

Bleeding patterns after immediate vs. conventional oral contraceptive initiation: a randomized, controlled trial ☆

OBJECTIVE To compare bleeding patterns after immediate vs. conventional oral contraceptive (OC) initiation. DESIGN Randomized controlled trial. SETTING University-based clinic. PATIENT(S) One hundred thirteen women initiating combination OCs. INTERVENTION(S) Participants received a 4-month supply of a monophasic 35-microg ethinyl E(2) (EE) OC and a bleeding diary, were randomized to immediate or conventional OC start, underwent monthly telephone follow-up, and after 90 days returned the diary and completed an exit interview. MAIN OUTCOME MEASURE(S) Total number of bleeding-spotting days, using the World Health Organization 90-day reference period method. Comparisons were made by trial assignment (immediate vs. conventional) and cycle day of OC initiation (day 8+ vs. days 1-7). RESULT(S) There was no significant difference in the number of bleeding-spotting days (mean difference: -0.5 days; 95% CI: -3.4 to 2.3) or any other bleeding parameter between the immediate and conventional starters, or days 1-7 and day 8+ starters. CONCLUSION(S) Immediate start of OCs does not induce bleeding patterns different from conventional starting regimens. Concern about adverse bleeding patterns should not be considered a justification for instructing women to wait until menses before starting OCs.

Vaginal ring contraception

The contraceptive vaginal ring is a relatively new combined hormonal contraceptive method. Ethinyl estradiol and etonogestrel are rapidly absorbed through the vaginal epithelium and result in a steady serum concentration. Studies have demonstrated that the efficacy and safety of the ring are equivalent to oral contraceptives (OCs). Patients report being highly satisfied with the vaginal ring and report fewer systemic side effects than do OC users. The ring provides effective cycle control as well as symptom relief for women with menorrhagia, dysmenorrhea and polycystic ovarian syndrome. A new combined contraceptive ring containing Nestorone and ethinyl estradiol is currently being investigated in a Phase 3 trial. A progesterone-releasing vaginal ring appropriate for lactating women is available in Chile and Peru. Recent studies have demonstrated that vaginal rings can also be effective means of delivering antiretroviral drugs that provide protection from HIV.

Women's decision making regarding choice of second trimester termination method for pregnancy complications

To describe how women terminating a pregnancy for fetal or maternal complications decide between surgical (dilation and evacuation [D&E]) and medical abortion.

Implementation of expedited partner therapy among women with chlamydia infection at an urban family planning clinic.

Background: Reinfection with chlamydia is common and expedited partner therapy (EPT) decreases reinfection in clinical trials. Many clinical practices have adopted EPT as the principal treatment strategy for male partners. Little is known about its application and effectiveness in a community setting. Methods: We conducted a retrospective cohort study of all female patients with chlamydia between 2004 and 2005 at a university-based family planning clinic. We abstracted demographic and clinical information from charts, including partner treatment strategy. We collected data on reinfection at 3 months and 1 year using a computerized database of laboratory results within the medical system. Results: During 2004 to 2005, 499 women tested positive for chlamydia. Of the 466 women treated, EPT was given to 323 women (69.3%). No baseline characteristics were associated with EPT provision. Only 40% of women returned for a retest within 3 months. Reinfection at 3 months was 4.8%. Patients who received EPT were as likely to be reinfected than those who did not receive EPT (odds ratio, 1.6; 95% confidence interval, 0.2–13.7). Conclusions: Although EPT was not associated with decreased reinfection, it remains an option for partner treatment. This study highlights the ongoing need to address compliance with retesting within 3 months.

Obesity as a Risk Factor for Complications After Second-Trimester Abortion by Dilation and Evacuation.

OBJECTIVE: To evaluate the association between obesity (body mass index [BMI] 30 or higher) and dilation and evacuation (D&E) complications. METHODS: We conducted a retrospective cohort study of women who underwent D&E abortion from February 2009 to April 2013 at a hospital-based abortion practice in California. We evaluated the association between obesity and risk of complication after D&E using logistic regression. We defined complications a priori as cervical laceration, hemorrhage, uterine atony, anesthesia complications, uterine perforation, disseminated intravascular coagulation, and retained products of conception. We defined major complications as those requiring hospitalization, transfusion, or further surgical intervention. RESULTS: Complications occurred in 442 of 4,520 D&Es (9.8%), with equal proportions in obese and nonobese women (9.8%). Major complications occurred in 78 (1.7%) patients. After adjustment for age, ethnicity, prior vaginal delivery, prior cesarean delivery, and gestational duration, there was no association between BMI and D&E complications. Any individual complication was associated with each additional week of gestation (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.3–1.4), prior vaginal delivery (OR 1.5, 95% CI 1.2–1.9) and prior cesarean delivery (OR 1.8, 95% CI 1.4–2.3). Major complications were associated with each additional week of gestation (OR 1.3, 95% CI 1.1–1.4) and cesarean delivery (OR 1.8, 95% CI 1.1–3.1). CONCLUSION: We found no association between obesity and D&E complications. Our findings are consistent with previous studies demonstrating that later gestational duration is associated with an increased risk of complications. Obesity may not warrant referral to a high-risk abortion center, particularly because referral-associated delay might increase the risk of complications. LEVEL OF EVIDENCE: II

Maternal-fetal medicine subspecialists' provision of second-trimester termination services

OBJECTIVE Most abortions for pregnancy complications occur in the second trimester. Little is known about whether maternal-fetal medicine subspecialists (MFMs) perform terminations for these women. STUDY DESIGN We surveyed all members of Society of Maternal Fetal Medicine by e-mail or mail regarding second-trimester abortion provision. We conducted analyses of whether MFMs perform abortions, by what method, and how frequently. RESULTS Our response rate was 32.4% (689/2,125). Over two-thirds of respondents perform either dilation and evacuation (D&E) or induction; 31% perform D&Es. Male gender, frequent chorionic villus sampling provision, and being trained in D&E during fellowship are associated with performing D&Es. Nonprovision of any second-trimester abortion is significantly associated with age over 50, nonacademic practice setting, and less supportive abortion attitudes (p < 0.001). A nonsignificant trend toward association between south/southeast region and nonprovision of any second-trimester abortion is seen (p = 0.09). CONCLUSION Many MFMs include D&E and induction termination services in their practice. Supporting current D&E providers and expanding training options for MFMs may optimize care for women diagnosed with serious pregnancy complications.

Characteristics of women who undergo second-trimester abortion in the setting of a fetal anomaly ☆

BACKGROUND Most women diagnosed with a fetal anomaly terminate the pregnancy. Little is known about utilization of two procedures: dilation and evacuation (D&E) and induction termination. STUDY DESIGN This retrospective cohort study included all women seen at the University of California, San Francisco (UCSF) Prenatal Diagnosis Center (PDC) who underwent a second-trimester abortion for an anomalous pregnancy from 2005 to 2008. We abstracted variables from the PDC database and medical charts to identify predictors associated with undergoing D&E. RESULTS Three quarters of the 192 women underwent D&E (n=148). Higher maternal age, proximity to UCSF, earlier gestational age, singleton gestation and genetic anomaly were associated with undergoing D&E. In adjusted analysis, earlier gestational age and singleton gestation were associated with undergoing D&E. CONCLUSIONS The D&E procedure was more commonly utilized for terminating an anomalous pregnancy at UCSF than medical induction. Further inquiry is needed to explore how provider counseling influences the choice of D&E vs. induction.

Distance Traveled for an Abortion and Source of Care After Abortion

OBJECTIVE To examine the association between distance traveled for an abortion and site of postabortion care among low-income women. METHODS We conducted a retrospective cohort study using claims data from 39,747 abortions covered by Californias Medicaid program in 2011-2012. Primary outcomes were the odds of abortion-related visits to an emergency department (ED) and the original abortion site, and the secondary outcome was total abortion care costs. We used mixed-effects logistic regression adjusting for patient and abortion characteristics to examine the associations between distance traveled and subsequent abortion-related care at each location. RESULTS Among all abortions (N=39,747), 3% (95% CI 2.9-3.3, n=1,232) were followed by an ED visit (3% first-trimester aspirations, 2% second trimester or later, and 4% medication abortions) and 25% (95% CI 24.1-24.9, n=9,745) were followed by a visit to the original abortion site (4% first-trimester aspirations, 3% second-trimester or later, and 77% medication abortions). Women traveling farther for their abortions had higher odds of visiting an ED (100 or more miles compared with less than 25 miles, first-trimester aspirations: adjusted odds ratio [OR] 2.29, 95% CI 1.50-3.49; medication abortions: adjusted OR 2.30, 95% CI 1.34-3.93) and lower odds of returning to their abortion site for follow-up (100 or more miles compared with less than 25 miles, first-trimester aspirations: adjusted OR 0.36, 95% CI 0.18-0.70; second trimester or later: adjusted OR 0.52, 95% CI 0.31-0.88; and medication abortions: adjusted OR 0.33, 95% CI 0.23-0.50). Costs were consistently higher when subsequent care occurred at an ED rather than the abortion site (median cost