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Mifepristone and misoprostol versus osmotic dilator use prior to surgical abortion at 15–18 weeks: a noninferiority study
Abstracts / Contraception 90 (2014) 298–351 (p=.66). Blood loss of more than 50 mL occurred among a small number of women who continued the anticoagulant (EBL 51–100 mL, 4/35; 101–250 mL, 2/35; 250–500 mL, 2/35) and discontinued it (EBL 51–100 mL, 1/17; 101–250 mL, 1/17; 250–500 mL, 0/17). The two patients with an EBL between 250 and 500 mL were 12 weeks’ and 12+4 weeks’ gestation. Conclusions: Blood loss is minimal for most anticoagulated women undergoing surgical abortion before 14 weeks. Two patients anticoagulated at the time of abortion had a clinically significant blood loss (250–500 mL).
http://dx.doi.org/10.1016/j.contraception.2014.05.051
P31 MIFEPRISTONE AND MISOPROSTOL VERSUS OSMOTIC DILATOR USE PRIOR TO SURGICAL ABORTION AT 15–18 WEEKS: A NONINFERIORITY STUDY Borgatta L Boston University, Boston, MA, USA Sonalkar S, McClusky J, Kattan D, Paris A, Petricone R, Finesseth M Objectives: Cervical preparation is recommended before surgical evacuation of second-trimester pregnancies. Both mechanical (osmotic dilator) and pharmacologic (misoprostol) methods are used. The combination of mifepristone and misoprostol may permit evacuation without the need for osmotic dilators. Methods: A randomized controlled trial of 50 women with pregnancies at 15–18 menstrual weeks was performed. Group 1 was administered mifepristone 200 mg orally 24 h prior to uterine evacuation plus misoprostol 400 mcg buccally 2 h prior to the procedure. Group 2 underwent osmotic dilator insertion 24 h before the procedure. The primary outcome was total procedure time, from insertion of the speculum to removal of the speculum. Secondary outcomes included the time from start of instrument use to the end of the procedure, cervical dilation and side effects. Results: For total procedure time, mifepristone (median, 13.5 min), was similar to osmotic dilators (median, 14.5 min). Inferiority of 3 min was rejected (pb.001). Operative time (from intrauterine instrumentation to speculum removal) was also noninferior (mifepristone median, 9.0 min, osmotic dilator median, 8.5 min). Initial dilation was reduced with mifepristone (42F vs. 56F), but dilation at the start of instrumentation was similar (58F vs. 60F). Physicians rated ease of procedure similarly for both techniques. Women had more cramping and bleeding overnight with osmotic dilators. Women in both groups said they would prefer mifepristone if they ever needed another procedure. Conclusions: Use of a pharmacologic method of cervical preparation was noninferior to osmotic dilators and presents an alternative to use of osmotic dilators.
http://dx.doi.org/10.1016/j.contraception.2014.05.052
P32 DOCUMENTING WOMEN’S EXPERIENCES WITH POSTABORTION SUPPORT IN ONTARIO LaRoche KJ University of Ottawa, Ottawa, Ottawa ON, Canada Foster AM Objectives: Abortion has been legalized without federal restrictions in Canada for more than 25 years. Ontario is Canada’s most populous province
307
where more than 33,000 terminations are reported annually. The majority of women receive abortion care from 12 clinics across the province and from a number of providing hospitals. This study aimed to explore women’s expressed desire for postabortion support services in Ontario; document the priorities expressed by women in seeking postabortion support; and identify actionable strategies to improve postabortion support services across Ontario. Methods: In 2012–2013, we conducted in-depth, open-ended interviews with 60 Anglophone women from the Greater London, Ottawa, Thunder Bay, Timmins and Toronto areas who had recently had an abortion. We purposively recruited women aged 18–24 and 25 or older and aimed to rigorously explore the compounding issues of age and geography on women’s abortion experiences. Results: One third of women expressed a desire for postabortion support to discuss their terminations, yet few women were able to access a timely, affordable, nondirective service. Women were uncertain as to how to find external support services; most contacted a provider recommended by the abortion facility or searched online. Women, especially those without supplementary insurance, found wait times and costs prohibitive. Women were enthusiastic about a talkline format citing anonymity and convenience as the main advantages. Conclusions: There is a demonstrated need for postabortion support services across Ontario. Efforts to expand access to timely, affordable and nonjudgmental services are warranted. http://dx.doi.org/10.1016/j.contraception.2014.05.053
P33 RISK FACTORS FOR COMPLICATION AFTER SECONDTRIMESTER DILATION AND EVACUATION Lederle L University of California, San Francisco, San Francisco, CA, USA Steinauer J, Montgomery A, Aksel S, Drey E, Kerns J Objectives: To determine the association between body mass index (BMI) and complications after dilation and evacuation (D&E). Methods: In our cohort study, we prospectively collected demographic, medical and operative data between 2009 and 2013 in an academic, urban, U.S. abortion clinic. Using any complication as our primary outcome, we conducted logistic regression with BMI dichotomized as b30 vs. ≥30. Our logistic model included known predictors for complications (prior cesarean section, gestational duration) and any other variables associated with complications in the unadjusted analysis (p≤.1). Major complications were defined as those requiring surgery, transfusion or admission. Results: Of 4576 D&Es between 14 and 24 weeks, 9.8% (n=446) met criteria for complications. The proportion of major complications was 1.8% (n=80). In the unadjusted analysis, increasing gestational duration, greater parity, need for further dilation, nonwhite ethnicity and prior cesarean section were significantly associated with complications (p≤.1). After adjustment, the strongest predictor was prior cesarean section (OR 4.9, 95% CI 2.8–8.7). Women with a BMI of at least 30 had increased odds of complication (OR 1.4, 95% CI 1.1–1.7). Other independent predictors included greater parity (OR 1.3, 95% CI 1.2–1.4), older age (OR 1.1, 95% CI 1.04–1.1), nonwhite ethnicity (OR 1.3, 95% CI 1.02–1.6) and each additional week of gestation (OR 1.4, 95% CI 1.1–1.6). Conclusions: Major complications after D&Es are rare (b2%). Obese women may be at a slightly increased risk of complication. Given that we found only a small associated risk, obesity may not warrant referral to higher acuity providers. We plan to conduct further analyses to understand the relationship between obesity and complication type. http://dx.doi.org/10.1016/j.contraception.2014.05.054
http://dx.doi.org/10.1016/j.contraception.2014.05.051
P31 MIFEPRISTONE AND MISOPROSTOL VERSUS OSMOTIC DILATOR USE PRIOR TO SURGICAL ABORTION AT 15–18 WEEKS: A NONINFERIORITY STUDY Borgatta L Boston University, Boston, MA, USA Sonalkar S, McClusky J, Kattan D, Paris A, Petricone R, Finesseth M Objectives: Cervical preparation is recommended before surgical evacuation of second-trimester pregnancies. Both mechanical (osmotic dilator) and pharmacologic (misoprostol) methods are used. The combination of mifepristone and misoprostol may permit evacuation without the need for osmotic dilators. Methods: A randomized controlled trial of 50 women with pregnancies at 15–18 menstrual weeks was performed. Group 1 was administered mifepristone 200 mg orally 24 h prior to uterine evacuation plus misoprostol 400 mcg buccally 2 h prior to the procedure. Group 2 underwent osmotic dilator insertion 24 h before the procedure. The primary outcome was total procedure time, from insertion of the speculum to removal of the speculum. Secondary outcomes included the time from start of instrument use to the end of the procedure, cervical dilation and side effects. Results: For total procedure time, mifepristone (median, 13.5 min), was similar to osmotic dilators (median, 14.5 min). Inferiority of 3 min was rejected (pb.001). Operative time (from intrauterine instrumentation to speculum removal) was also noninferior (mifepristone median, 9.0 min, osmotic dilator median, 8.5 min). Initial dilation was reduced with mifepristone (42F vs. 56F), but dilation at the start of instrumentation was similar (58F vs. 60F). Physicians rated ease of procedure similarly for both techniques. Women had more cramping and bleeding overnight with osmotic dilators. Women in both groups said they would prefer mifepristone if they ever needed another procedure. Conclusions: Use of a pharmacologic method of cervical preparation was noninferior to osmotic dilators and presents an alternative to use of osmotic dilators.
http://dx.doi.org/10.1016/j.contraception.2014.05.052
P32 DOCUMENTING WOMEN’S EXPERIENCES WITH POSTABORTION SUPPORT IN ONTARIO LaRoche KJ University of Ottawa, Ottawa, Ottawa ON, Canada Foster AM Objectives: Abortion has been legalized without federal restrictions in Canada for more than 25 years. Ontario is Canada’s most populous province
307
where more than 33,000 terminations are reported annually. The majority of women receive abortion care from 12 clinics across the province and from a number of providing hospitals. This study aimed to explore women’s expressed desire for postabortion support services in Ontario; document the priorities expressed by women in seeking postabortion support; and identify actionable strategies to improve postabortion support services across Ontario. Methods: In 2012–2013, we conducted in-depth, open-ended interviews with 60 Anglophone women from the Greater London, Ottawa, Thunder Bay, Timmins and Toronto areas who had recently had an abortion. We purposively recruited women aged 18–24 and 25 or older and aimed to rigorously explore the compounding issues of age and geography on women’s abortion experiences. Results: One third of women expressed a desire for postabortion support to discuss their terminations, yet few women were able to access a timely, affordable, nondirective service. Women were uncertain as to how to find external support services; most contacted a provider recommended by the abortion facility or searched online. Women, especially those without supplementary insurance, found wait times and costs prohibitive. Women were enthusiastic about a talkline format citing anonymity and convenience as the main advantages. Conclusions: There is a demonstrated need for postabortion support services across Ontario. Efforts to expand access to timely, affordable and nonjudgmental services are warranted. http://dx.doi.org/10.1016/j.contraception.2014.05.053
P33 RISK FACTORS FOR COMPLICATION AFTER SECONDTRIMESTER DILATION AND EVACUATION Lederle L University of California, San Francisco, San Francisco, CA, USA Steinauer J, Montgomery A, Aksel S, Drey E, Kerns J Objectives: To determine the association between body mass index (BMI) and complications after dilation and evacuation (D&E). Methods: In our cohort study, we prospectively collected demographic, medical and operative data between 2009 and 2013 in an academic, urban, U.S. abortion clinic. Using any complication as our primary outcome, we conducted logistic regression with BMI dichotomized as b30 vs. ≥30. Our logistic model included known predictors for complications (prior cesarean section, gestational duration) and any other variables associated with complications in the unadjusted analysis (p≤.1). Major complications were defined as those requiring surgery, transfusion or admission. Results: Of 4576 D&Es between 14 and 24 weeks, 9.8% (n=446) met criteria for complications. The proportion of major complications was 1.8% (n=80). In the unadjusted analysis, increasing gestational duration, greater parity, need for further dilation, nonwhite ethnicity and prior cesarean section were significantly associated with complications (p≤.1). After adjustment, the strongest predictor was prior cesarean section (OR 4.9, 95% CI 2.8–8.7). Women with a BMI of at least 30 had increased odds of complication (OR 1.4, 95% CI 1.1–1.7). Other independent predictors included greater parity (OR 1.3, 95% CI 1.2–1.4), older age (OR 1.1, 95% CI 1.04–1.1), nonwhite ethnicity (OR 1.3, 95% CI 1.02–1.6) and each additional week of gestation (OR 1.4, 95% CI 1.1–1.6). Conclusions: Major complications after D&Es are rare (b2%). Obese women may be at a slightly increased risk of complication. Given that we found only a small associated risk, obesity may not warrant referral to higher acuity providers. We plan to conduct further analyses to understand the relationship between obesity and complication type. http://dx.doi.org/10.1016/j.contraception.2014.05.054