Outpatient medical management of later second trimester abortion (18–23.6 weeks) with procedural evacuation backup: A large case series☆
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ABSTRACT:
SUBMITTER: Chandrasekaran S
PROVIDER: S-EPMC10950721 | biostudies-literature | 2024 Jan
REPOSITORIES: biostudies-literature
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Project description:IntroductionThe future of training in second trimester surgical abortions with dilation and evacuation (D&E) procedures faces ongoing legal and political scrutiny; thus, adjuncts to standard clinical experiences are exceedingly important. We sought to build medical trainees' surgical familiarity with D&Es using a realistic simulation model.MethodsThe simulation began with an instructional video reviewing accessible and affordable materials used to build the fetal model (vaginal swabs, styrofoam ball, and putty) and the uterine model (collapsible water bottle). Required personnel roles included surgeon, surgical assistant, and facilitator. A standardized rubric was used to evaluate learners' mastery of procedural learning objectives, and a pre- and postsimulation assessment measured learners' knowledge and confidence before and after the activity. Consistency between iterations was maintained with use of standardized prompts and lectures. Total time for the activity, including setup and debrief, was 1 hour.ResultsEighteen residents, medical students, and attendings participated in the simulation, and 100% completed the assessment. There was a demonstrated improvement in clinical knowledge of D&E steps (56% presimulation vs. 94% postsimulation, p < .001) and increased surgical confidence in performing D&Es after participating in the simulation (28% presimulation vs. 89% postsimulation, p < .001). The participants with prior clinical experience in performing D&Es rated the fetal, uterine, and cervical models as realistic components in the simulation.DiscussionA gap now exists in access to clinical D&E training. This low-fidelity D&E simulation is a training tool that can fill this gap and improve learners' familiarity with this surgical procedure.
| S-EPMC11753717 | biostudies-literature
Project description:IntroductionDespite the need for providers skilled in second-trimester dilation and evacuation (D&E) procedures, there are few second-trimester abortion training opportunities for OB/GYN residents and other health care trainees. Barriers to such training include restrictive state laws and institutional policies, lack of trained faculty, and limited procedural volume. Simulation-based D&E training is, therefore, a critical tool for OB/GYN residents and other medical professionals to achieve clinical competency.MethodsThis simulation for OB/GYN residents centers on a 29-year-old woman at 18 weeks gestation with intrauterine fetal demise, requiring learners to perform a second-trimester D&E and manage an unexpected postprocedural hemorrhage. We designed the simulation to be used with a high-fidelity mannequin. Personnel roles required for the simulation included an anesthesiologist, medical assistant, OR nurse, and two OB/GYN faculty. Learner performance was assessed using a pre- and postsimulation learner evaluation, a critical action checklist, and a focus group with simulation facilitators.ResultsForty-nine residents participated over an 8-year period. Learners demonstrated improved competency performing a second-trimester D&E and increased confidence managing postprocedural hemorrhage after participating in this simulation. In addition, focus group participants reported that a majority of learners demonstrated confidence and effective communication with team members while performing in a decision-making role.DiscussionIn addition to improving learners' clinical competency and surgical confidence for second-trimester D&E procedures, this simulation serves as a valuable instrument for the standardized assessment of learners' performance, as well as an opportunity for all participants to practice teamwork and communication in a high-acuity setting.
| S-EPMC10425577 | biostudies-literature
Project description:BackgroundThe availability of modern contraception including long-acting reversible contraceptives (LARC), is a fundamental component of postabortion care. Findings from a recent randomized controlled trial (RCT) in South Africa comparing immediate to delayed insertion of the copper intrauterine device (IUD) after medical abortion (MA) at 17-20 gestational weeks showed that immediate insertion resulted in higher IUD use at 6 weeks postabortion, but that expulsion rates were significantly higher than for delayed insertion. This study aims to explore barriers, facilitators, and context-specific factors relevant to the implementation of immediate IUD provision after second trimester medical abortion.MethodsWe performed a qualitative study alongside the RCT in which we conducted in-depth interviews with 14 staff providing healthcare to study participants and 24 study participants. Research questions explored barriers and facilitators to implementation of immediate IUD insertion, contraceptive decision-making, and the impact of context and supplementary trial activities on service provision. Interviews were recorded and transcribed, with translation into English if needed. We performed a triangulated thematic analysis at the level of the transcribed interview text.ResultsContraceptive counselling at the abortion facility by a study nurse improved knowledge, corrected misconceptions, and increased demand for the IUD postabortion. Women expressed a clear preference for immediate insertion. Convenience, protection from pregnancy and privacy issues were paramount and women expressed preference for engagement with staff who knew their abortion history, and with whom they had an established connection. Doctors and nurses were generally in favour of immediate insertion and said it could be incorporated into standard care if women wanted this. This contrasted with the need for interventions by the research team to reinforce adherence by staff to provide contraception as allocated during the trial.ConclusionsWomen and staff favour immediate IUD insertion after second trimester medical abortion, but service delivery may require structures that ensure timely insertion postabortion, continuity of care, communication that mitigates loss to follow-up and training of staff to ensure competence.
| S-EPMC8645068 | biostudies-literature
Project description:Oxytocin is a neurohormone that is routinely administered to patients during dilation and evacuation procedures (D&E) to control bleeding despite minimal evidence in support of this common practice. In this study, the authors sought to evaluate patients with hypotension after receiving oxytocin during D&E procedures. The secondary data from a double-blind, randomized, placebo-controlled trial involving 112 patients who underwent a D&E at 18-24 weeks gestation and prophylactically received an intravenous bolus of either 30 units of oxytocin in 500 mL of normal saline or 500 mL of saline alone at the start of the procedure were analyzed. Anesthesia providers measured blood pressure before, at the time of, and after study medication administration in 5-minute increments until the end of the procedure. No differences in demographic characteristics or mean blood pressure between the 2 groups were observed. The proportion of hypotensive patients was not statistically different at 5 minutes following fluid bolus (oxytocin 25% versus placebo 13%, P=.09). The proportion of hypotensive patients was similar by 10 minutes (oxytocin 20% versus placebo 16%, P=.62). A sample size of 112 provided the ability to detect a 23% difference in the proportion of patients who experienced hypotension (2-sided 95% CI, power of 80%). These findings suggest that oxytocin may have a transient hypotensive effect.
| S-EPMC9727702 | biostudies-literature
Project description:ObjectiveTo assess whether indicators of limited access to services explained changes in rates of second-trimester abortion after implementation of a restrictive abortion law in Texas.MethodsWe used cross-sectional vital statistics data on abortions performed in Texas before (November 1, 2011-October 31, 2012) and after (November 1, 2013-October 31, 2014) implementation of Texas' abortion law. We conducted monthly mystery client calls for information about abortion facility closures and appointment wait times to calculate distance from women's county of residence to the nearest open Texas facility, the number of open abortion facilities in women's region of residence (facility network size), and days until the next consultation visit. We estimated mixed-effects logistic regression models to assess the association between obtaining abortion care after the law's implementation and having a second-trimester abortion (12 weeks of gestation or more), after adjustment for distance, network size, and wait times.ResultsOverall, 64,902 Texas-resident abortions occurred in the period before the law was introduced and 53,174 occurred after its implementation. After implementation, 14.5% of abortions were performed at 12 weeks of gestation or more, compared with 10.5% before the law (P<.001; unadjusted odds ratio [OR] 1.45; 95% CI 1.40-1.50). Adjusting for distance to the nearest facility and facility network size reduced the odds of having a second-trimester abortion after implementation (OR 1.17; 95% CI 1.10-1.25). Women living 50-99 miles from the nearest facility (vs less than 10 miles) had higher odds of second-trimester abortion (OR 1.24; 95% CI 1.11-1.39), as did women in regions with less than one facility per 250,000 reproductive-aged women compared with women in areas that had 1.5 or more facilities (OR 1.57; 95% CI 1.41-1.75). After implementation, women waited 1 to 14 days for a consultation visit; longer waits were associated with higher odds of second-trimester abortion.ConclusionIncreases in second-trimester abortion after the law's implementation were due to women having more limited access to abortion services.
| S-EPMC6435408 | biostudies-literature
Project description:ObjectiveTo determine the frequency of diagnostic indications among women seeking to terminate pregnancies for reasons of fetal abnormality, spontaneous fetal demise, or a genetic disorder in a private outpatient clinic specializing in late outpatient abortion procedures.MethodA total of 1005 women requested termination of pregnancy for reasons of genetic disorder, fetal anomaly, or fetal demise over 20 years (1992-2012). Gestational ages ranged from 12 to 39 weeks. In all cases, a documented diagnosis of fetal abnormality or fetal demise was made prior to referral. Records were reviewed to verify fetal diagnosis for all patients seeking termination of pregnancy for reasons of fetal disorder. Major complications included major unintended surgery, hemorrhage requiring transfusion, or pelvic infection.ResultsPreoperative diagnoses included the following: chromosomal abnormalities (n = 378), genetic syndromes and single gene disorders (n = 30), structural anomalies (n = 494), and other conditions (n = 103). These include 26 cases of spontaneous fetal demise and nine selective terminations of one abnormal twin. The major complication rate was 0.5%.ConclusionsThe majority of diagnoses were in the categories of genetic disorder and neurologic abnormality.
| S-EPMC4238813 | biostudies-literature
Project description:ObjectiveTo evaluate the efficacy of a paracervical block to decrease pain during osmotic dilator insertion before second-trimester abortion.MethodsIn this double-blind, randomized trial, 41 women undergoing Laminaria insertion before a second-trimester abortion received either a paracervical block with 18 mL 1% lidocaine and 2 mL sodium bicarbonate or a sham block. Women were between 14 and 23 6/7 weeks of gestation. The primary outcome was pain immediately after insertion of Laminaria. Women assessed their pain on a 100-mm visual analog scale. Secondary outcomes included assessment of pain at other times during the insertion procedure and overall satisfaction with pain control. To detect a 25-mm difference in pain immediately after Laminaria insertion, at an α of 0.05 and 80% power, we aimed to enroll 20 patients in each arm.ResultsFrom May 2015 to December 2015, 20 women received a paracervical block and 21 received a sham block. Groups were similar in demographics, including parity, history of surgical abortion, and number of Laminaria placed. The paracervical block reduced pain after Laminaria insertion (median scores 13 mm [interquartile range 2-39] compared with 54 mm [interquartile range 27-61], P=.01, 95% CI -47.0 to -4.0). Women who received a paracervical block also reported higher satisfaction with overall pain control throughout the entire Laminaria insertion procedure (median scores 95 mm [interquartile range 78-100] compared with 70 mm [interquartile range 44-90], P=.05, 95% CI 0.0-37.0).ConclusionParacervical block is effective at reducing the pain of Laminaria insertion. Additionally, a paracervical block increases overall patient satisfaction with pain control during Laminaria placement.Clinical trial registrationClinicalTrials.gov, NCT02454296.
| S-EPMC5529236 | biostudies-literature
Project description:Background: Data on abortion procedures costs are scarce in low- and middle-income countries. In Mexico, the only known study was conducted more than a decade ago, with data from years before the abortion legislation. This study estimated the costs, from the health system’s perspective, of surgical and medical abortion methods commonly used by women who undergo first-trimester abortion in Mexico. Methods: Data were collected on staff time, salaries, medications, consumables, equipment, imaging, and lab studies, at 5 public general hospitals. A bottom-up micro-costing approach was used. Results: Surgical abortion costs were US$201 for manual vacuum aspiration and US$298 for sharp curettage. The cost of medical abortion with misoprostol was US$85. The use of cervical ripening increases the costs by up to 18%. Staff comprised up to 72% of total costs in surgical abortions. Hospitalization was the area where most of the spending occurred, due to the staff and post-surgical surveillance required. Conclusions: Our estimates reflect the costs of “real-life” implementation and highlight the impact on costs of the overuse of resources not routinely recommended by clinical guidelines, such as cervical ripening for surgical abortion. This information will help decision-makers to generate policies that contribute to more efficient use of resources.
| S-EPMC9511298 | biostudies-literature
Project description:BackgroundConjoined twins are a rare clinical event occurring in about 1 per 250,000 live births. Though the prognosis of conjoined twins is generally low, there is limited evidence as to the optimal method of pregnancy termination, particularly in cases of advanced gestational age. We report a successful dilation and evacuation (D&E) done for conjoined twins at 22 weeks of gestation.Case presentationA 20-year-old primigravid woman was diagnosed with a conjoined, thoraco-omphalopagus twin pregnancy after undergoing a detailed two-dimensional (2D) fetal ultrasound anatomic scanning. Assessment and counseling were done by a multidisciplinary team. The team discussed the prognosis and options of management with the patient. The patient opted for termination of pregnancy. Different options of termination were discussed and the patient consented for D&E, with the possibility of reverting to hysterotomy in case intraoperative difficulty was encountered. A 2-day cervical preparation followed by D&E was done under spinal anesthesia and ultrasound guidance.ConclusionIn this patient, D&E was done successfully without complications. Adequate cervical preparation, pain control, and ultrasound guidance during the procedure are critical for optimal outcomes. A literature review of methods of pregnancy termination for conjoined twins in the second trimester revealed 75% delivered vaginally through medical induction while 18% underwent cesarean section. Only one other report described successful D&E for conjoined twins after 20 weeks. D&E can be safely performed for carefully selected cases of conjoined twins beyond 20 weeks' gestations avoiding the need for induction or hysterotomy.
| S-EPMC8140421 | biostudies-literature
Project description:BackgroundSneathia amnii (formerly designated as Leptotrichia amnionii ) was first described in 2002 in the USA. Members of the genus Sneathia can be part of the normal flora of the genitourinary tract, but have been implicated in invasive (mostly gynaecological) infections.Case presentationTo the best of our knowledge, here we present the first case of S. amnii infection in Belgium, in a young woman presenting with fever leading to second trimester septic abortion.ConclusionDespite its pathogenicity, S. amnii remains an underrated cause of infections due to inherent difficulties with conventional laboratory methods. By extracting the bacterial DNA directly from the blood culture broth and performing a 16S ribosomal RNA gene sequence analysis we succeeded in identifying S. amnii as the most probable cause of the septic abortion in our patient.
| S-EPMC8749150 | biostudies-literature