Immediate versus delayed insertion of the copper intrauterine device after medical abortion at 17-20 gestational weeks: a randomised controlled trial.

INTRODUCTION: This trial reports on use of the copper intrauterine device (IUD) after immediate compared with delayed insertion following medical abortion at 17-20 gestational weeks (GW). METHODS: This randomised controlled trial was conducted at one tertiary hospital and five community healthcare centres in Cape Town, South Africa. Eligible consenting women were randomised to immediate (within 24 hours) or delayed (3 weeks post-abortion) insertion of the copper IUD. Follow-up was at 6 weeks, 3 months and 6 months. Main outcomes were use of the original IUD and use of any IUD, including replacement IUDs at 6 weeks post-abortion. Secondary outcomes included rates of expulsion and malposition at 6 weeks, use of any IUD at 3 and 6 months, and acceptability of the IUD. RESULTS: We recruited and randomised 114 women admitted for elective medical abortion between August 2018 and June 2019. In the immediate and delayed study arms, respectively, 45/55 (82%) and 12/57 (21%) women received the IUD as planned. By intention-to-treat, 56% in the immediate and 19% in the delayed arms were using the original IUD at 6 weeks (p<0.001), and 76% in the immediate and 40% in the delayed arms were using any IUD (p<0.001). Complete expulsion or removal occurred in 32% in the immediate and 7% in the delayed arms (p=0.044). CONCLUSIONS: Insertion of an IUD immediately after medical abortion at 17-20 GW results in increased use after 6 weeks compared with delayed insertion, however expulsion rates are higher than with interval insertion. CLINICAL TRIALS REGISTRATION: NCT03505047), Pan African Trials Registry (www.pactr.org), 201804003324963.

Diagnostic Bias in the COVID-19 Pandemic: A Series of Short Cases.

During the COVID-19 pandemic, healthcare systems have faced unprecedented pressures. One challenge has been to promptly recognise non-COVID-19 conditions. Cognitive bias due to the availability heuristic may cause difficulties in reaching the correct diagnosis. Confirmation bias may also affect imaging interpretation. We report three cases with an alternative final diagnosis in whom COVID-19 was initially suspected: (a) Pneumocystis jirovecii pneumonia with unrecognised HIV infection; (b) pulmonary lymphangitis carcinomatosis; and (c) ST elevation myocardial infarction causing acute pulmonary oedema. To help mitigate bias, there is no substitute for thoughtful clinical assessment and critical appraisal when evaluating new information and formulating the differential diagnosis. LEARNING POINTS: The availability heuristic during the recent pandemic may lead to cognitive bias in favour of COVID-19 diagnosis and delayed recognition of other conditions, especially in patients presenting with similar non-specific features.Confirmation bias towards COVID-19 can also affect the interpretation of pulmonary imaging which is central to the investigation of cases with suspected pneumonitis.Diagnostic bias can be mitigated by recognition and allowing time for a thorough clinical history and methodical examination of the patients.

Difficult etonogestrel implant removals in South Africa: A review of 74 referred cases.

OBJECTIVES: To assess etonogestrel contraceptive implant location and outcomes among women referred for "difficult" removal to a specialist clinic in South Africa. STUDY DESIGN: We performed a retrospective review of cases referred to our clinic for removal of nonpalpable, deep, migrated, or damaged implants, or failed removals from March to August 2017. RESULTS: Most (n = 68, 92%) of the 74 referrals were nonpalpable in our clinic. We used ultrasound for localization and successfully removed 72 implants (97%) in the outpatient clinic. CONCLUSION: With proper protocols and equipment, localization and removal of nonpalpable implants can be safely and effectively achieved in an outpatient African setting. IMPLICATIONS: Access to providers specially trained in ultrasound localization should be available in all settings where implants are offered. Providing timely access to safe and effective implant removals in routine and difficult cases is essential to ensuring that implant programs are in alignment with rights-based, client-centered family planning principles.

Clinical Outcomes and Women's Experiences before and after the Introduction of Mifepristone into Second-Trimester Medical Abortion Services in South Africa.

OBJECTIVE: To document clinical outcomes and women's experiences following the introduction of mifepristone into South African public sector second-trimester medical abortion services, and compare with historic cohorts receiving misoprostol-only. METHODS: Repeated cross-sectional observational studies documented service delivery and experiences of women undergoing second-trimester medical abortion in public sector hospitals in the Western Cape, South Africa. Women recruited to the study in 2008 (n = 84) and 2010 (n = 58) received misoprostol only. Those recruited in 2014 (n = 208) received mifepristone and misoprostol. Consenting women were interviewed during hospitalization by study fieldworkers with respect to socio-demographic information, reproductive history, and their experiences with the abortion. Clinical details were extracted from medical charts following discharge. Telephone follow-up interviews to record delayed complications were conducted 2-4 weeks after discharge for the 2014 cohort. RESULTS: The 2014 cohort received 200 mg mifepristone, which was self-administered 24-48 hours prior to admission. For all cohorts, following hospital admission, initial misoprostol doses were generally administered vaginally: 800 mcg in the 2014 cohort and 600 mcg in the earlier cohorts. Women received subsequent doses of misoprostol 400 mcg orally every 3-4 hours until fetal expulsion. Thereafter, uterine evacuation of placental tissue was performed as needed. With one exception, all women in all cohorts expelled the fetus. Median time-to-fetal expulsion was reduced to 8.0 hours from 14.5 hours (p<0.001) in the mifepristone compared to the 2010 misoprostol-only cohort (time of fetal expulsion was not recorded in 2008). Uterine evacuation of placental tissue using curettage or vacuum aspiration was more often performed (76% vs. 58%, p<0.001) for those receiving mifepristone; major complication rates were unchanged. Hospitalization duration and extreme pain levels were reduced (p<0.001), but side effects of medication were similar or more common for the mifepristone cohort. Overall satisfaction remained unchanged (95% vs. 91%), while other acceptability measures were higher (p<0.001) for the mifepristone compared to the misoprostol-only cohorts. CONCLUSION: The introduction of a combined mifepristone-misoprostol regimen into public sector second-trimester medical abortion services in South Africa has been successful with shorter time-to-abortion events, less extreme pain and greater acceptability for women. High rates of uterine evacuation for placental tissue need to be addressed.