Justin T. Diedrich

Preferences for Decision-Making About Contraception and General Health Care Among Reproductive Age Women at an Abortion Clinic

OBJECTIVE Studies suggest that not all patients desire shared decision making, and little is known about decision making around contraception. This study compared decision-making preferences for contraception to preferences for general health among reproductive-aged women. METHODS 257 women receiving abortion care in an urban hospital completed a survey which included questions adapted from the Problem-Solving Decision-Making Scale about their preferences for medical decision making. RESULTS Women were significantly more likely to desire autonomous decision making about contraception than about their general health care (50% vs. 19%, p<.001). No patient characteristics were associated with contraceptive decision-making preferences. Women with Medicaid insurance were more likely to desire autonomous decision making about contraception than about general health care (51% vs. 17%, p<.001). CONCLUSION Women desire more autonomy in their contraceptive decisions than in their decisions about general health care. PRACTICE IMPLICATIONS Health care providers should be attentive to the existence of variation in preferences in decision making across health domains. Contraceptive providers should proactively assess decisional preferences to ensure the most appropriate counseling is provided to each individual.

Uterine artery embolization in postabortion hemorrhage.

OBJECTIVE: To summarize the efficacy of postabortion uterine artery embolization in cases of refractory hemorrhage. METHODS: Forty-two women were identified who had postabortion uterine artery embolization at San Francisco General Hospital between January 2000 and August 2007. Seven underwent embolization for hemorrhage caused by abnormal placentation. RESULTS: Embolization was successful in 90% (38 of 42) of cases. All failures (n=4) were in patients who had confirmed abnormal placentation. However, three of seven women (43%) with probable accreta diagnosed by ultrasonography were treated successfully with uterine artery embolization. Two patients experienced complications of uterine artery embolization. These complications—one contrast reaction and one femoral artery embolus—were treated without further sequelae. CONCLUSION: Uterine artery embolization is an alternative to hysterectomy in patients with postabortion hemorrhage refractory to conservative measures, especially when hemorrhage is caused by uterine atony or cervical laceration. LEVEL OF EVIDENCE: III

Effect of Prior Cesarean Delivery on Risk of Second-Trimester Surgical Abortion Complications

OBJECTIVE: To estimate second-trimester surgical abortion complication rates and to estimate the effect of past cesarean delivery on the risk of complications. METHODS: Demographic, medical, and operative data were collected prospectively between October 2004 and March 2007 in an academic, urban, U.S. abortion clinic. Complication and intervention rates were calculated. Multivariable logistic regression models were used to evaluate risk factors for a major complication, hemorrhage, cervical laceration, and atony. RESULTS: We included 2,973 second-trimester surgical abortions. Cervical laceration (3.3%), atony (2.6%), and hemorrhage (1.0%) were the most common complications. The rate of major complications (eg, transfusion, disseminated intravascular coagulation, and reoperation) was 1.3%. In multivariable logistic regression modeling, a history of two or more cesarean deliveries was the strongest predictor for having a major complication (odds ratio [OR] 7.4, 95% confidence interval [CI] 3.4–15.8), while additional predictors included gestational age of 20 weeks or more (OR 4.4, 95% CI 2.0–11.4) and insufficient initial cervical preparation requiring further dilation (OR 2.6, 95% CI 1.2–5.4). CONCLUSION: Second-trimester surgical abortions were associated with a major complication rate of approximately 1%. A history of two or more cesarean deliveries was associated with a sevenfold increase in odds of major complication and was the strongest independent risk factor for a major complication. LEVEL OF EVIDENCE: III

Association of short-term bleeding and cramping patterns with long-acting reversible contraceptive method satisfaction

OBJECTIVE We sought to examine the short-term (3- and 6-month), self-reported bleeding and cramping patterns with intrauterine devices (IUDs) and the contraceptive implant, and the association of these symptoms with method satisfaction. STUDY DESIGN We analyzed 3- and 6-month survey data from IUD and implant users in the Contraceptive CHOICE Project, a prospective cohort study. Participants who received a long-acting reversible contraceptive (LARC) method (levonorgestrel-releasing intrauterine system [LNG-IUS], copper IUD, or the etonogestrel implant) and completed their 3- and 6-month surveys were included. Univariable and multivariable analyses were performed to examine the association of bleeding and cramping patterns with short-term satisfaction. RESULTS Our analytic sample included 5011 Contraceptive CHOICE Project participants: 3001 LNG-IUS users, 826 copper IUD users, and 1184 implant users. At 3 months, >65% of LNG-IUS and implant users reported no change or decreased cramping, while 63% of copper IUD users reported increased menstrual cramping. Lighter bleeding was reported by 67% of LNG-IUS users, 58% of implant users, and 8% of copper IUD users. Satisfaction of all LARC methods was high (≥90%). LARC users with increased menstrual cramping (relative risk adjusted [RRadj], 0.78; 95% confidence interval [CI], 0.72-0.85), heavier bleeding (RRadj, 0.83; 95% CI, 0.76-0.92), and increased bleeding frequency (RRadj, 0.73; 95% CI, 0.67-0.80) were less likely to report being very satisfied at 6 months. CONCLUSION Regardless of the LARC method, satisfaction at 3 and 6 months is very high. Changes in self-reported bleeding and cramping are associated with short-term LARC satisfaction.

Complications of Surgical Abortion

Surgical abortion is one of the most common procedures performed in reproductive-aged women and when performed by a skilled provider in the appropriate setting, it is one of the safest surgeries. Though the risk of complications is low, it increases exponentially with gestational age. Factors increasing risk of morbidity may be demographic, such as increasing patient age; medical, such as prior cesarean delivery; and procedural, such as inadequate dilation. This chapter will provide information on how to recognize factors that increase risk, steps to minimize risk, and to identify and manage complications promptly.

Long-term utilization and continuation of intrauterine devices

OBJECTIVE We compared the 48 and 60 month continuation rates of levonorgestrel (LNG) and copper (Cu) intrauterine devices (IUDs) among women enrolled in the Contraceptive CHOICE Project (CHOICE). Our primary outcome was continuation at 48 months. STUDY DESIGN This is a prospective cohort study of women who received an IUD through CHOICE. We randomly selected women who had either LNG or Cu IUDs inserted between January 2008 and June 2009 and contacted them by telephone. Once contacted and consented, they were asked whether they were still using their IUD. Women who reported discontinuation of the IUD were asked for the reasons and subsequent contraceptive use. Survival analysis using Cox proportional hazards was performed to assess for factors associated with discontinuation and to calculate hazard ratios. RESULTS Of the 460 women we attempted to contact, 321 (70%) were reached for interviews. Continuation data on the remaining 139 women were available from CHOICE and its substudies. Continuations at 48 and 60 months were 62.3% and 51.7% for LNG IUD and 64.2% and 55.9% for the Cu IUD, respectively. Continuation at 48 months was highest among women older than 29 years of age at insertion (LNG IUD, 72.5%; Cu IUD, 77.1%). Women younger than 24 years of age had the lowest 48 month continuation (LNG IUD, 55.4%, and Cu IUD, 53.2%). In univariable and multivariable analysis, demographic characteristics, menstrual profile, and pregnancy history were not associated with discontinuation. Age older than 29 years was associated with less discontinuation than those 24-29 years of age (hazard ratio, 0.67, 95% confidence interval, 0.47-0.96). CONCLUSION IUD continuation remains high (> 60%) at 48 months with no difference between Cu and LNG IUDs.

Second-trimester induction of labor.

Second-trimester abortions are most commonly performed in the United States via dilation and evacuation; however, there are instances in which the use of systemic abortifacients is necessary. Lack of trained staff to perform late abortion procedures, fetal anomalies, and patient preference are important considerations when selecting the method of termination. Second-trimester abortions with misoprostol-only protocols require higher doses, side effects are more common, and the time to complete the abortion is longer in comparison to mifepristone-misoprostol combinations. Feticidal agents are recommended to avoid transient fetal survival. This chapter will review medical induction methods between gestational ages of 14 and 24 weeks that are commonly used in the United States.

Choice of the levonorgestrel intrauterine device, etonogestrel implant or depot medroxyprogesterone acetate for contraception after aspiration abortion

OBJECTIVE Women who have abortions are at high risk of contraception discontinuation and subsequent unintended pregnancy. The objective of this analysis was to identify factors associated with choice of highly effective, long-acting, progestin-only contraceptive methods after abortion. STUDY DESIGN Women presenting for surgical abortion who selected the levonorgestrel intrauterine device (IUD), the progestin implant or the progestin injection (depot medroxyprogesterone acetate or DMPA) as their postabortion contraceptives were recruited to participate in a 1-year prospective cohort study. We used multivariable multinomial logistic regression to identify factors associated with choosing long-acting reversible contraceptives (IUD or implant) compared to DMPA. RESULTS A total of 260 women, aged 18-45 years, enrolled in the study, 100 of whom chose the IUD, 63 the implant and 97 the DMPA. The women were 24.9 years old on average; 36% were black, and 29% were Latina. Fifty-nine percent had had a previous abortion, 66% a prior birth, and 55% were undergoing a second-trimester abortion. In multivariable analyses, compared with DMPA users, women who chose the IUD or the implant were less likely to be currently experiencing intimate partner violence (IPV); reported higher stress levels; weighed more; and were more likely to have finished high school, to have used the pill before and to report that counselors or doctors were helpful in making the decision (all significant at p<.05, see text for relative risk ratios and confidence intervals.) In addition, women who chose the IUD were less likely to be black (p<.01), and women who chose the implant were more likely to report that they would be unhappy to become pregnant within 6 months (p<.05) than DMPA users. CONCLUSION A variety of factors including race/ethnicity, past contraceptive use, feelings towards pregnancy, stress and weight were different between LARC and DMPA users. Notably, current IPV was associated with choice of DMPA over the IUD or implant, implying that a desire to choose a hidden method may be important to some women and should be included in counseling. IMPLICATIONS In contraceptive counseling, after screening for IPV, assessing patients stress and taking a history about past contraceptive use, clinicians should discuss whether these factors might affect a patients choice of method.

Secondary prevention of cervical cancer part 1: screening for cervical cancer and its precursors.

Discussion of screening for cervical cancer and it precursors, management of abnormal cervical cancer screening test, and evidence-based management of women with cervical intraepithelial neoplasia.

Contribution of Exocervical Biopsy, Endocervical Curettage, and Colposcopic Grading in Diagnosing High-Grade Cervical Intraepithelial Neoplasia.

Objective To determine the utility of random biopsy and endocervical curettage (ECC) during colposcopy among women who ultimately underwent cervical excisional biopsy. Materials and Methods In a retrospective observational study, the charts were reviewed of every patient who underwent cervical excisional procedure performed between June 2010 and August 2011, including the antecedent colposcopic examination and any pathological specimens. A random sample of 15% all pathologic specimens was reviewed. Practice of biopsy, use of ECC, demographic factors, referral cytology results, lesion distribution, and size were assessed for correlation with high-grade cervical intraepithelial neoplasia 2 or worse (CIN 2+). Results A total of 555 patients were included in our analysis. Of them, 333 (60%) had CIN 2+ on colposcopy or excision. CIN 2+ was most likely in younger women and those referred for high-grade cytology. Among 111 women with no visual lesion seen at colposcopy, 66 underwent ECC alone, 33 had ECC and random biopsy, 9 were referred straight to excision, and 3 underwent random biopsy alone. Of the 99 who underwent ECC, this was consistent with the highest-grade lesion in 68% of cases. Among the 36 with random biopsy, this was consistent with the highest-grade lesion in 72% of cases. At the time of colposcopy, there were 326 who had CIN 2+ diagnosed with satisfactory colposcopy. Biopsy and ECC were performed in 278 cases. In 235 cases, biopsy alone showed CIN 2+; in 43, the biopsy and ECC both showed CIN 2+. In the remaining 48 cases, CIN 2+ was diagnosed with ECC alone. Conclusions In those ultimately treated with excision, younger women and those whose referral cytology was high-grade both were at higher risk of high-grade histology. Random biopsy and ECC (even among satisfactory colposcopy) were significantly associated with disclosure of high-grade pathology.