A retrospective analysis of factors associated with deep contraceptive implant removals compared to superficial removals.

OBJECTIVE: To identify factors associated with the need for a deep etonogestrel contraceptive implant removal as compared to superficial removal. STUDY DESIGN: We conducted a retrospective cohort study of patients undergoing contraceptive implant removal from January 2014 to January 2023. We extracted key patient characteristics from electronic health record review and compared patients requiring deep removal versus routine superficial removal using Chi-squared, Fischer's exact, and Mann-Whitney U test. A multivariate logistic regression identified variables associated with increased odds of requiring a deep implant removal. RESULTS: The deep and superficial removal groups included 162 and 585 patients, respectively. Deep removal was associated with younger age at removal (median 25.0 vs 26.0 years, p = 0.005), lower body mass index (BMI) at insertion (median 23.2 kg/m2 vs 26.6 kg/m2, p = 0.024), BMI≥ 40 kg/m2 at removal (15.2% vs 7.0%, p = 0.007), weight gain during implant use (median 6.6 vs 1.8 kg, p ≤ 0.001), longer duration of use (median 36.0 vs 27.5 months, p < 0.001), implant exchange (37.3% vs 17.4%, p < 0.001), and insertion by non-physician (43.3% vs 19.3%, p < 0.001) or non-obstetrican and gynecologist (31.4% vs 11.8%, p < 0.001). Lower BMI at insertion (aOR 0.92, [95% CI 0.87-0.98]), weight gain during use (aOR 1.06 [95% CI 1.02-1.10]), and longer duration of use (aOR 1.05 [95% CI 1.02-1.07]) remained significantly associated with deep removal in regression analysis. CONCLUSION(S): We identified lower BMI at insertion, weight gain during use, and longer duration of use as independent factors associated with increased likelihood of needing a deep contraceptive implant removal. IMPLICATIONS: Clinicians should utilize proper technique when inserting contraceptive implants, especially in patients at risk for deep insertion, and ensure immediate referral to Centers of Experience for patients with non-palpable implants.

Complications of second trimester induction for abortion or fetal demise for patients with and without prior cesarean delivery.

OBJECTIVE: Compare complication rates of second trimester induction for abortion or fetal demise for patients with and without prior cesarean delivery. STUDY DESIGN: Retrospective cohort study examining induction for abortion or fetal demise for pregnancies from 14w0d to 23w6d gestation at 2 urban academic medical centers from 2009 to 2019. Exclusion criteria included preterm labor or cervical insufficiency, neonatal interventions, or if misoprostol was not the primary induction method. Complication rates were compared between those with no prior, 1 prior, and 2 or more (2+) prior cesarean deliveries. Complications analyzed were retained placenta, failed induction, infection, hemorrhage, blood transfusion, uterine rupture, intensive care unit admission, death, and readmission. Secondary analysis included cumulative misoprostol dosages and complete abortion rate within 24 hours. RESULTS: Of 520 patients, 411 patients had no prior cesarean delivery, 77 had 1 prior cesarean delivery, and 32 had 2+ prior cesarean deliveries. Eleven patients had a prior vertical uterine incision. About 26.5% of all patients received mifepristone. The 2+ prior cesarean delivery group was significantly older (35 vs 32 vs 32, p < 0.001) and more likely to be induced for fetal demise (62.5 vs 41.56 vs 39.17%, p = 0.04). Both cesarean groups were more likely to be obese (58.62 vs 49.35 vs 34.26%, p = 0.003). Patients with 2+ prior cesarean deliveries were more likely to experience uterine rupture (6.25 vs 0 vs 0%, p = 0.004), and require ICU admission (6.45 vs 1.3 vs 0.49%, p = 0.02). Secondary analysis outcomes were similar. Logistic regression showed patients with 2+ prior cesarean deliveries were more likely to experience a complication than those with 1 prior (adjusted odds ratio [aOR] 2.71, confidence interval [CI] 1.09-6.86, p = 0.03) or 0 prior cesarean deliveries (aOR 3.00, CI 1.30-7.02, p = 0.01). Patients with 1 prior or no prior cesarean deliveries had a similar risk of experiencing a complication (aOR 1.11, CI 0.64-1.89, p = 0.7). CONCLUSIONS: Most patients with prior cesarean deliveries can safely undergo induction in the second trimester for abortion or fetal demise. Patients with 2+ prior cesarean deliveries had a higher rate of at least 1 complication when compared to those with one or no prior cesarean delivery, despite similar misoprostol dosages and rates of complete abortion. IMPLICATIONS: This large 10-year retrospective study examines the impact of prior cesarean delivery on the safety of second trimester induction. While second trimester labor induction abortion remains an option for all patients, specialized counseling for patients with 2 or more prior cesarean deliveries may be warranted.