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Maternal fetal medicine management of lethal fetal anomalies after 24 weeks' gestation
296
ABSTRACTS / Contraception 86 (2012) 290–325
O19 CONTRACEPTION AFTER SECOND-TRIMESTER ABORTION: CHARACTERISTICS OF IMMEDIATE LARC ACCEPTORS AND COMPARATIVE REPEAT PREGNANCY RATES Hurley C University of Colorado Anschutz Medical Campus, Aurora, CO, USA Sheeder J, Westhoff C, Teal S Objectives: To compare characteristics of immediate post-abortion LARC acceptors versus those choosing other contraceptives among second-trimester abortion patients and to evaluate 12-month repeat pregnancy and abortion. Methods: Participants undergoing elective second-trimester abortion at New York Presbyterian Hospital were offered immediate postabortion initiation of any contraceptive. Those choosing IUDs or implants comprised the LARC group; women selecting any other contraceptive were comparators. Group characteristics were compared. Twelve months of postprocedure records were analyzed for discontinuation of LARC method, repeat pregnancy and repeat abortion. Results: Of 305 women who enrolled, 171 (56.1%) received LARC (11% implants, 48% copper-Ts, 41% LNG-IUS). The cohort was predominantly young, Latina, parous and publicly insured. Women with at least two children were more likely to choose LARC than nulliparas, OR=2.53 (95% CI 1.33– 4.81). No other variables were associated with choosing LARC; no differences existed between choosers of different LARC methods. Non-LARC acceptors (n=134) chose DMPA (26%), COCs (18%), condoms (7%), the vaginal ring (5%) or other methods (12%); 32% were not specified. By 12 months, 13.1% of enrolled women had become pregnant (nonacceptors, 23.9%; LARC, 4.7%; OR=6.41, 95% CI 2.83–14.49). In all, 14.2% of the non-LARC group and 0.6% of the LARC group had repeat abortions (OR 9.2, 95% CI 2.7–32.3). All LARC pregnancies occurred after device removal. Age, gravidity, prior abortions and race were associated with repeat pregnancy among LARC recipients; among non-LARC recipients, no variables were associated with repeat pregnancy. In multivariable analysis of repeat pregnancy risk, only choosing LARC remained significant. Among LARC acceptors, 12.9% discontinued ≤12 months. Time to discontinuation did not differ among LARC methods. Conclusions: LARC immediately following second-trimester abortion has high continuation and prevents repeat pregnancy and abortion in the ensuing 12 months.
O20 THE SENSITIVITY OF MANUAL VERSUS ELECTRIC VACUUM ASPIRATION IN DETECTING COMPLETED ABORTION AT LESS THAN 6 WEEKS OF GESTATION Dean G Planned Parenthood of New York City, New York, NY, USA Mount Sinai School of Medicine, New York City, NY, USA
no POC on gross inspection underwent repeat aspiration as necessary and serial hCG monitoring. All patients were scheduled for a follow-up visit 2–6 weeks after surgery. The primary outcome was detection of POC in subjects with subsequently confirmed completed abortion. Results: A total of 251 subjects were randomized to MVA and 247 to EVA. Among subjects in the MVA group, 84% had POC identified and a completed abortion subsequently confirmed, compared with 77% in the EVA group (p=.06, RR=0.78, 95% CI 0.60–1.03). In pregnancies with sac size 3 mm or less, including no visible sac, 20% of MVA subjects had accurate identification of POC, compared with 13% of EVA subjects (p=0.05, RR=0.78, 95% CI 0.40–1.53). Tissue reports of physicians and medical assistants had 90% concordance. Seventy subjects (14%) required hCG monitoring to confirm completed abortion. There were seven ongoing pregnancies and one ectopic pregnancy. Conclusions: MVA and EVA had similar sensitivity in the detection of POC in very early surgical abortion. Early aspiration is very effective, although hCG monitoring may be necessary to confirm complete abortion.
POSTER ABSTRACT PRESENTATIONS P1 MEDICATION ABORTION FOLLOW-UP: THE USE OF EARLY POST-PROCEDURAL SERUM HCG Pocius K Brigham and Women's Hospital, Boston, MA, USA Mauer R, Fortin J, Charm S, Bartz D Objectives: To describe a nomogram for serum beta-human chorionic gonadotropin (hCG) values on Days 2–6 after medication abortion. Methods: This is a retrospective record review of all women who underwent medication abortion with 200 mg of oral mifepristone followed by 800 μg buccal misoprostol and had both a serum hCG level drawn on Day 1 (day of mifepristone administration) and a repeat value drawn on Days 2–6. These women represent a subpopulation of medication abortion patients undergoing concurrent evaluation for possible ectopic pregnancy because of a lack of intrauterine gestational sac with yolk sac on pelvic ultrasound. Regression analysis is performed to identify a decline in early serum hCG values that may suggest procedure success. Results: Ninety-five patients met study criteria. The mean gestational age of their pregnancies was 5 weeks and 4 days. The mean hCG value on the day of mifepristone administration (Day 1) was 16,680 IU. The mean percent of hCG decline was 58% (SD 28) on Day 3, 72% (SD 38) on Day 4, and 86% (SD 9) by Day 5. Five subjects required a second dose of misoprostol or uterine evacuation to complete the abortion. Fifty-three women (56%) completed clinician-requested follow-up. Thirty-one women (33%) missed one follow-up appointment and another 11 (11%) missed two or more. Conclusions: The early hCG decline following medication abortion with mifepristone and misoprostol is similar to that seen in other settings of pregnancy interruption. These finding could allow for simplified medication abortion follow-up in early pregnancy.
Colarossi L, Porsch L, Betancourt G, Jacobs A, Paul M Objectives: To determine whether manual vacuum aspiration (MVA) or electric vacuum aspiration (EVA) improves physicians' ability to accurately identify products of conception (POC) in abortions at less than 6 weeks' gestation. Methods: A total of 498 pregnant women presenting for surgical abortion with mean gestational sac diameter of b12 mm or no visible sac on ultrasound were randomized to either MVA or EVA. Tissue exam was performed by the operating physician (not blinded to group assignment) and by a trained medical assistant (blinded to group assignment). Patients with
P2 MATERNAL FETAL MEDICINE MANAGEMENT OF LETHAL FETAL ANOMALIES AFTER 24 WEEKS' GESTATION Jacobs A Mount Sinai Medical Center, New York, New York, USA Paul M, Dean G, Porsch L, Wasenda E, Luthy D
ABSTRACTS / Contraception 86 (2012) 290–325 Objectives: To assess clinical practices of US maternal fetal medicine specialists relating to termination of pregnancies (TOP) for lethal fetal anomalies diagnosed after 24 weeks' gestation. Methods: We mailed surveys to all 2119 members of the Society of Maternal Fetal Medicine to ascertain demographics and clinical practices pertaining to TOP for late-diagnosed lethal fetal anomalies. A total of 869 members (41%) responded. Of these, 52 respondents were no longer practicing, leaving 817 surveys for analysis. Results: Of the 817 respondents, 212 (26%) indicated that they do not discuss TOP with pregnant patients with lethal fetal anomalies diagnosed after 24 weeks' gestation. Of all the maternal fetal medicine specialists surveyed, only 328 (41%) responded that their practices are involved in any way with the care of women who desire TOP in this medical situation. Local services for women seeking TOP were limited: only 52% of physicians indicated that their patients could obtain a TOP at their affiliated medical centers or through providers within 50 miles. The respondents from medical centers not offering TOP cited multiple reasons for the lack of local TOP services, including state or federal regulation (323, or 67%), hospital policies (237, or 49%), lack of skilled physicians (68, or 14%), reluctance of hospital staff (162, or 34%), economic considerations (15, or 3%) and community resistance or antiabortion activism (73, or 15%). Conclusions: This national survey suggests that many maternal fetal medicine specialists do not offer adequate services to pregnant women with lethal fetal anomalies who desire TOP. Education and policy changes may improve access.
P3 PARACERVICAL COMPARED WITH INTRACERVICAL LIDOCAINE FOR SUCTION CURETTAGE WITHOUT CONSCIOUS SEDATION: A RANDOMIZED CONTROLLED AND BLINDED CLINICAL TRIAL Conolly J University of California San Diego, San Diego, CA, USA
297
P4 EVALUATION OF PATIENT SATISFACTION AND PROCEDURE WAIT TIMES FOR UTERINE EVACUATION WITH MANUAL VERSUS ELECTRIC VACUUM ASPIRATION Hofler L Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA Owen L, Dodge L, Hacker M, Haider S Objectives: Outpatient manual vacuum aspiration (MVA) is as safe and effective as electric vacuum aspiration (EVA) in the operating room (OR). This study was conducted to determine whether outpatient MVA expedites care while maintaining patient satisfaction. Methods: We conducted a prospective observational study of a convenience sample of patients undergoing surgical management of spontaneous abortion, induced abortion, or retained products of conception with either outpatient MVA under local anesthesia or EVA in the OR. Procedure length, time from decision to procedure and patient satisfaction were analyzed. Results: One hundred thirty-eight women completed surveys; 48 underwent outpatient MVA and 90 underwent EVA in the OR. Most patients (77%) in the MVA group reported waiting fewer than two hours from the time of their decision to the procedure, while most EVA patients (74%) reported waiting more than 12 h (pb0.001). The median procedure duration was significantly shorter in the MVA group (20 vs. 33 min, pb0.001). There was a trend in the MVA group toward reporting higher satisfaction with time to procedure and with the overall procedure, though these differences were not significant (both p=.15). Conclusions: Outpatient MVA under local anesthesia is a suitable alternative to OR-based EVA for management of spontaneous and induced abortion as well as retained products of conception. Outpatient MVA is associated with shorter time from diagnosis to procedure and shorter procedure length, and it is acceptable to patients. Integration of outpatient MVA into clinical settings would add timeand resource-saving options for uterine evacuation while maintaining a positive patient experience.
P5 Mankowski J, Mody S, Lukacz E, Kingston J Objectives: Prior investigation has shown no difference between paracervical and intracervical administration of local anesthesia during suction curettage for first-trimester abortion with patients receiving conscious sedation. This study investigated these blocks without the use of conscious sedation during this procedure. The hypothesis of the investigation was that intracervical block would provide better pain relief than the institution standard of paracervical nerve block. Methods: We performed a randomized controlled blinded clinical trial in which subjects received standardized paracervical or intracervical block for local anesthesia during dilation and suction curettage for first-trimester abortion. Pain scores from a 10-cm visual analog scale (VAS) were collected by a blinded assistant at three time points during the procedure: before intervention, after dilation and after suction curettage. Student's t tests were used to compare the mean VAS scores to determine statistical significance between block types. Results: Eighty-nine participants, 45 receiving paracervical block and 44 intracervical block, were included in an intention-to-treat analysis that showed no statistically significant differences between control and treatment groups at the three time points (p=.245, p=.937 and p=.993, respectively). We also analyzed the change in pain score from baseline to dilation and the change from baseline to curettage, and again found no difference (p=.608 and p=.641, respectively). Conclusions: Without the use of conscious sedation, neither paracervical nor intracervical anesthetic block showed superior pain control over the other. Both blocks are acceptable methods of pain control for first-trimester suction curettage.
IMMEDIATE POST-ABORTION IUD INSERTION COMPARED WITH PLANNED INSERTION AT ABORTION FOLLOW-UP: A COST ANALYSIS Salcedo J University of California, Los Angeles, Los Angeles, California, USA Sorensen A, Parvataneni R, Rodriguez M Objectives: To evaluate whether providing immediate post-abortion intrauterine device (IUD) insertion, compared with a policy of scheduling IUD insertion for the abortion follow-up appointment, is cost saving. Methods: A decision analytic model was created to evaluate potential cost savings of post-abortion versus delayed IUD insertion. The model analyzed a theoretical cohort of Medicaid-eligible women in California undergoing abortion and desiring IUD placement. A 1-year Markov cycle was used. Costs of direct medical care, including unintended pregnancy, were obtained from the literature. A standard 3% discount rate was used. One- and 5-year time horizons were considered. Univariate and bivariate sensitivity analyses, as well as Monte Carlo simulation, were performed. Results: Considering only direct medical costs, immediate post-abortion IUD provision decreases public program expenditures by $111 per woman compared with scheduling IUD placement for the follow-up appointment. Five years following abortion, this public cost savings reaches $810 per woman. When public health insurance program costs are included for the woman and pregnancies resulting in births, immediate post-abortion IUD provision saves $1956 per woman over 5 years. The savings increases to $4296 per woman
ABSTRACTS / Contraception 86 (2012) 290–325
O19 CONTRACEPTION AFTER SECOND-TRIMESTER ABORTION: CHARACTERISTICS OF IMMEDIATE LARC ACCEPTORS AND COMPARATIVE REPEAT PREGNANCY RATES Hurley C University of Colorado Anschutz Medical Campus, Aurora, CO, USA Sheeder J, Westhoff C, Teal S Objectives: To compare characteristics of immediate post-abortion LARC acceptors versus those choosing other contraceptives among second-trimester abortion patients and to evaluate 12-month repeat pregnancy and abortion. Methods: Participants undergoing elective second-trimester abortion at New York Presbyterian Hospital were offered immediate postabortion initiation of any contraceptive. Those choosing IUDs or implants comprised the LARC group; women selecting any other contraceptive were comparators. Group characteristics were compared. Twelve months of postprocedure records were analyzed for discontinuation of LARC method, repeat pregnancy and repeat abortion. Results: Of 305 women who enrolled, 171 (56.1%) received LARC (11% implants, 48% copper-Ts, 41% LNG-IUS). The cohort was predominantly young, Latina, parous and publicly insured. Women with at least two children were more likely to choose LARC than nulliparas, OR=2.53 (95% CI 1.33– 4.81). No other variables were associated with choosing LARC; no differences existed between choosers of different LARC methods. Non-LARC acceptors (n=134) chose DMPA (26%), COCs (18%), condoms (7%), the vaginal ring (5%) or other methods (12%); 32% were not specified. By 12 months, 13.1% of enrolled women had become pregnant (nonacceptors, 23.9%; LARC, 4.7%; OR=6.41, 95% CI 2.83–14.49). In all, 14.2% of the non-LARC group and 0.6% of the LARC group had repeat abortions (OR 9.2, 95% CI 2.7–32.3). All LARC pregnancies occurred after device removal. Age, gravidity, prior abortions and race were associated with repeat pregnancy among LARC recipients; among non-LARC recipients, no variables were associated with repeat pregnancy. In multivariable analysis of repeat pregnancy risk, only choosing LARC remained significant. Among LARC acceptors, 12.9% discontinued ≤12 months. Time to discontinuation did not differ among LARC methods. Conclusions: LARC immediately following second-trimester abortion has high continuation and prevents repeat pregnancy and abortion in the ensuing 12 months.
O20 THE SENSITIVITY OF MANUAL VERSUS ELECTRIC VACUUM ASPIRATION IN DETECTING COMPLETED ABORTION AT LESS THAN 6 WEEKS OF GESTATION Dean G Planned Parenthood of New York City, New York, NY, USA Mount Sinai School of Medicine, New York City, NY, USA
no POC on gross inspection underwent repeat aspiration as necessary and serial hCG monitoring. All patients were scheduled for a follow-up visit 2–6 weeks after surgery. The primary outcome was detection of POC in subjects with subsequently confirmed completed abortion. Results: A total of 251 subjects were randomized to MVA and 247 to EVA. Among subjects in the MVA group, 84% had POC identified and a completed abortion subsequently confirmed, compared with 77% in the EVA group (p=.06, RR=0.78, 95% CI 0.60–1.03). In pregnancies with sac size 3 mm or less, including no visible sac, 20% of MVA subjects had accurate identification of POC, compared with 13% of EVA subjects (p=0.05, RR=0.78, 95% CI 0.40–1.53). Tissue reports of physicians and medical assistants had 90% concordance. Seventy subjects (14%) required hCG monitoring to confirm completed abortion. There were seven ongoing pregnancies and one ectopic pregnancy. Conclusions: MVA and EVA had similar sensitivity in the detection of POC in very early surgical abortion. Early aspiration is very effective, although hCG monitoring may be necessary to confirm complete abortion.
POSTER ABSTRACT PRESENTATIONS P1 MEDICATION ABORTION FOLLOW-UP: THE USE OF EARLY POST-PROCEDURAL SERUM HCG Pocius K Brigham and Women's Hospital, Boston, MA, USA Mauer R, Fortin J, Charm S, Bartz D Objectives: To describe a nomogram for serum beta-human chorionic gonadotropin (hCG) values on Days 2–6 after medication abortion. Methods: This is a retrospective record review of all women who underwent medication abortion with 200 mg of oral mifepristone followed by 800 μg buccal misoprostol and had both a serum hCG level drawn on Day 1 (day of mifepristone administration) and a repeat value drawn on Days 2–6. These women represent a subpopulation of medication abortion patients undergoing concurrent evaluation for possible ectopic pregnancy because of a lack of intrauterine gestational sac with yolk sac on pelvic ultrasound. Regression analysis is performed to identify a decline in early serum hCG values that may suggest procedure success. Results: Ninety-five patients met study criteria. The mean gestational age of their pregnancies was 5 weeks and 4 days. The mean hCG value on the day of mifepristone administration (Day 1) was 16,680 IU. The mean percent of hCG decline was 58% (SD 28) on Day 3, 72% (SD 38) on Day 4, and 86% (SD 9) by Day 5. Five subjects required a second dose of misoprostol or uterine evacuation to complete the abortion. Fifty-three women (56%) completed clinician-requested follow-up. Thirty-one women (33%) missed one follow-up appointment and another 11 (11%) missed two or more. Conclusions: The early hCG decline following medication abortion with mifepristone and misoprostol is similar to that seen in other settings of pregnancy interruption. These finding could allow for simplified medication abortion follow-up in early pregnancy.
Colarossi L, Porsch L, Betancourt G, Jacobs A, Paul M Objectives: To determine whether manual vacuum aspiration (MVA) or electric vacuum aspiration (EVA) improves physicians' ability to accurately identify products of conception (POC) in abortions at less than 6 weeks' gestation. Methods: A total of 498 pregnant women presenting for surgical abortion with mean gestational sac diameter of b12 mm or no visible sac on ultrasound were randomized to either MVA or EVA. Tissue exam was performed by the operating physician (not blinded to group assignment) and by a trained medical assistant (blinded to group assignment). Patients with
P2 MATERNAL FETAL MEDICINE MANAGEMENT OF LETHAL FETAL ANOMALIES AFTER 24 WEEKS' GESTATION Jacobs A Mount Sinai Medical Center, New York, New York, USA Paul M, Dean G, Porsch L, Wasenda E, Luthy D
ABSTRACTS / Contraception 86 (2012) 290–325 Objectives: To assess clinical practices of US maternal fetal medicine specialists relating to termination of pregnancies (TOP) for lethal fetal anomalies diagnosed after 24 weeks' gestation. Methods: We mailed surveys to all 2119 members of the Society of Maternal Fetal Medicine to ascertain demographics and clinical practices pertaining to TOP for late-diagnosed lethal fetal anomalies. A total of 869 members (41%) responded. Of these, 52 respondents were no longer practicing, leaving 817 surveys for analysis. Results: Of the 817 respondents, 212 (26%) indicated that they do not discuss TOP with pregnant patients with lethal fetal anomalies diagnosed after 24 weeks' gestation. Of all the maternal fetal medicine specialists surveyed, only 328 (41%) responded that their practices are involved in any way with the care of women who desire TOP in this medical situation. Local services for women seeking TOP were limited: only 52% of physicians indicated that their patients could obtain a TOP at their affiliated medical centers or through providers within 50 miles. The respondents from medical centers not offering TOP cited multiple reasons for the lack of local TOP services, including state or federal regulation (323, or 67%), hospital policies (237, or 49%), lack of skilled physicians (68, or 14%), reluctance of hospital staff (162, or 34%), economic considerations (15, or 3%) and community resistance or antiabortion activism (73, or 15%). Conclusions: This national survey suggests that many maternal fetal medicine specialists do not offer adequate services to pregnant women with lethal fetal anomalies who desire TOP. Education and policy changes may improve access.
P3 PARACERVICAL COMPARED WITH INTRACERVICAL LIDOCAINE FOR SUCTION CURETTAGE WITHOUT CONSCIOUS SEDATION: A RANDOMIZED CONTROLLED AND BLINDED CLINICAL TRIAL Conolly J University of California San Diego, San Diego, CA, USA
297
P4 EVALUATION OF PATIENT SATISFACTION AND PROCEDURE WAIT TIMES FOR UTERINE EVACUATION WITH MANUAL VERSUS ELECTRIC VACUUM ASPIRATION Hofler L Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA Owen L, Dodge L, Hacker M, Haider S Objectives: Outpatient manual vacuum aspiration (MVA) is as safe and effective as electric vacuum aspiration (EVA) in the operating room (OR). This study was conducted to determine whether outpatient MVA expedites care while maintaining patient satisfaction. Methods: We conducted a prospective observational study of a convenience sample of patients undergoing surgical management of spontaneous abortion, induced abortion, or retained products of conception with either outpatient MVA under local anesthesia or EVA in the OR. Procedure length, time from decision to procedure and patient satisfaction were analyzed. Results: One hundred thirty-eight women completed surveys; 48 underwent outpatient MVA and 90 underwent EVA in the OR. Most patients (77%) in the MVA group reported waiting fewer than two hours from the time of their decision to the procedure, while most EVA patients (74%) reported waiting more than 12 h (pb0.001). The median procedure duration was significantly shorter in the MVA group (20 vs. 33 min, pb0.001). There was a trend in the MVA group toward reporting higher satisfaction with time to procedure and with the overall procedure, though these differences were not significant (both p=.15). Conclusions: Outpatient MVA under local anesthesia is a suitable alternative to OR-based EVA for management of spontaneous and induced abortion as well as retained products of conception. Outpatient MVA is associated with shorter time from diagnosis to procedure and shorter procedure length, and it is acceptable to patients. Integration of outpatient MVA into clinical settings would add timeand resource-saving options for uterine evacuation while maintaining a positive patient experience.
P5 Mankowski J, Mody S, Lukacz E, Kingston J Objectives: Prior investigation has shown no difference between paracervical and intracervical administration of local anesthesia during suction curettage for first-trimester abortion with patients receiving conscious sedation. This study investigated these blocks without the use of conscious sedation during this procedure. The hypothesis of the investigation was that intracervical block would provide better pain relief than the institution standard of paracervical nerve block. Methods: We performed a randomized controlled blinded clinical trial in which subjects received standardized paracervical or intracervical block for local anesthesia during dilation and suction curettage for first-trimester abortion. Pain scores from a 10-cm visual analog scale (VAS) were collected by a blinded assistant at three time points during the procedure: before intervention, after dilation and after suction curettage. Student's t tests were used to compare the mean VAS scores to determine statistical significance between block types. Results: Eighty-nine participants, 45 receiving paracervical block and 44 intracervical block, were included in an intention-to-treat analysis that showed no statistically significant differences between control and treatment groups at the three time points (p=.245, p=.937 and p=.993, respectively). We also analyzed the change in pain score from baseline to dilation and the change from baseline to curettage, and again found no difference (p=.608 and p=.641, respectively). Conclusions: Without the use of conscious sedation, neither paracervical nor intracervical anesthetic block showed superior pain control over the other. Both blocks are acceptable methods of pain control for first-trimester suction curettage.
IMMEDIATE POST-ABORTION IUD INSERTION COMPARED WITH PLANNED INSERTION AT ABORTION FOLLOW-UP: A COST ANALYSIS Salcedo J University of California, Los Angeles, Los Angeles, California, USA Sorensen A, Parvataneni R, Rodriguez M Objectives: To evaluate whether providing immediate post-abortion intrauterine device (IUD) insertion, compared with a policy of scheduling IUD insertion for the abortion follow-up appointment, is cost saving. Methods: A decision analytic model was created to evaluate potential cost savings of post-abortion versus delayed IUD insertion. The model analyzed a theoretical cohort of Medicaid-eligible women in California undergoing abortion and desiring IUD placement. A 1-year Markov cycle was used. Costs of direct medical care, including unintended pregnancy, were obtained from the literature. A standard 3% discount rate was used. One- and 5-year time horizons were considered. Univariate and bivariate sensitivity analyses, as well as Monte Carlo simulation, were performed. Results: Considering only direct medical costs, immediate post-abortion IUD provision decreases public program expenditures by $111 per woman compared with scheduling IUD placement for the follow-up appointment. Five years following abortion, this public cost savings reaches $810 per woman. When public health insurance program costs are included for the woman and pregnancies resulting in births, immediate post-abortion IUD provision saves $1956 per woman over 5 years. The savings increases to $4296 per woman