Medication and procedural abortions before 13 weeks gestation and risk of psychiatric disorders.

BACKGROUND: The proportion of abortions provided by medication in the United States and worldwide has increased greatly since the U.S. Food and Drug Administration approved mifepristone in 2000. While existing research has shown that abortion does not increase risk of mental health problems, no population-based study has examined specifically whether a procedural or medication abortion increases risk of mental health disorders. OBJECTIVE: This study examined whether mental health disorders increased in the shorter and longer-term after a medication or procedural abortion. STUDY DESIGN: Using Danish population registers' data, we conducted a prospective cohort study in which we included 72,424 females born in Denmark between 1980 and 2006, who were ages 12 to 38 during the study period and had a first first-trimester abortion before 13 weeks gestation in 2000 to 2018. Females with no previous psychiatric diagnoses were followed from 1 year before their abortion until their first psychiatric diagnosis, December 31, 2018, emigration from Demark, or death, whichever came first. Risk of any first psychiatric disorder was defined as a recorded psychiatric diagnosis at an in- or out-patient facility from the 1 year after to more than 5 years after a medication or procedural abortion relative to the year beforehand. Results were adjusted for calendar year, age, gestational age, partner status, prior mental and physical health, childbirth history, childhood environment, and parental mental health history. RESULTS: Females having medication (n=37,155) and procedural abortions (n=35,269) had the same risk of any first psychiatric diagnosis in the year after their abortion relative to the year before their abortion (medication abortion adjusted incidence rate ratio [MaIRR]=1.02, 95% confidence interval [CI]: 0.93-1.12; procedural abortion adjusted incidence rate ratio [PaIRR]=0.94, 95% CI: 0.86-1.02). Moreover, as more time from the abortion passed, the risk of a psychiatric diagnoses decreased relative to the year before their abortion for each abortion method (MaIRR 1-2 years after=0.89, 95% CI: 0.80-0.98; PaIRR 1-2 years after=0.81, 95% CI: 0.88-1.05; MaIRR 2-5 years after=0.77, 95% CI: 0.71-0.84; PaIRR 2-5 years after=0.72, 95% CI: 0.67-0.78; MaIRR 5+ years after=0.58, 95% CI: 0.53-0.63; PaIRR 5+ years after=0.54, 95% CI: 0.50-0.58). CONCLUSION: Because the risk of psychiatric diagnoses was the same in the year after relative to the year before a medication and procedural abortion and the risk did not increase as more time after the abortion increased, neither abortion method increased risk of mental health disorders in the shorter or longer-term.

Society of Family Planning Clinical Recommendation: Management of hemorrhage at the time of abortion.

Hemorrhage after abortion is rare, occurring in fewer than 1% of abortions, but associated morbidity may be significant. Although medication abortion is associated with more bleeding than procedural abortion, overall bleeding for the two methods is minimal and not clinically different. Hemorrhage can be caused by atony, coagulopathy, and abnormal placentation, as well as by such procedure complications as perforation, cervical laceration, and retained tissue. Evidence for practices around postabortion hemorrhage is extremely limited. The Society of Family Planning recommends preoperative identification of individuals at high risk of hemorrhage as well as development of an organized approach to treatment. Specifically, individuals with a uterine scar and complete placenta previa seeking abortion at gestations after the first trimester should be evaluated for placenta accreta spectrum. For those at high risk of hemorrhage, referral to a higher-acuity center should be considered. We propose an algorithm for treating postabortion hemorrhage as follows: (1) assessment and examination, (2) uterine massage and medical therapy, (3) resuscitative measures with laboratory evaluation and possible reaspiration or balloon tamponade, and (4) interventions such as embolization and surgery. Evidence supports the use of oxytocin as prophylaxis for bleeding with dilation and evacuation; methylergonovine prophylaxis, however, is associated with more bleeding at the time of dilation and evacuation. Future research is needed on tranexamic acid as prophylaxis and treatment and misoprostol as prophylaxis. Structural inequities contribute to bleeding risk. Acknowledging how our policies hinder or remedy health inequities is essential when developing new guidelines and approaches to clinical services.

Helping patients choose between pain control options for outpatient procedural abortion at less than 12 weeks' gestation.

OBJECTIVES: This study aimed to identify predictors of patient satisfaction with their chosen pain control regimen for procedural abortion at <12 weeks' gestation in the outpatient setting. STUDY DESIGN: In this prospective cohort study, we developed an instrument to evaluate predictors of satisfaction with pain control regimens among patients choosing local anesthesia alone (paracervical block with 20 mL of 1% buffered lidocaine) or local anesthesia plus intravenous (IV) moderate sedation with 100 mcg of fentanyl and 2 mg of midazolam. Our primary outcome was to identify predictors of satisfaction with both anesthesia cohorts as measured on a 4-point Likert scale, but due to high satisfaction levels in the IV group, we focused our analysis on the local anesthesia group. RESULTS: We enrolled 149 patients in the local anesthesia group and 155 in the moderate IV sedation group. The mean procedure pain scores were 6.9 (±2.1) out of 10 in the local group and 4.0 (±2.7) in the IV group (p < 0.0001). More women in the IV group (92%) were satisfied or very satisfied with the amount of pain relief they experienced compared to the local group (66%; p < 0.0001). In the univariable model, only being afraid of a minor medical procedure was predictive of less satisfaction with local anesthesia for pain control (relative risk 0.8 [95% CI, 0.6-0.9]). Age, gestational age, anticipated pain, self-reported pain tolerance, self-reported anxiety, discomfort with the abortion decision, and history of prior vaginal or cesarean delivery or induced abortion did not predict satisfaction levels. CONCLUSIONS: Fear of minor medical procedures was the only variable that predicted decreased satisfaction with local anesthesia alone for procedural abortion under 12 weeks. IMPLICATIONS: Reliable predictors for satisfaction with local anesthesia alone for procedural abortion in the outpatient setting remain elusive. Fear of minor medical procedures may serve as an indicator of decreased satisfaction and could be incorporated into patient counseling. Moderate IV sedation is associated with high satisfaction levels.

Effects of aromatherapy on patient satisfaction with procedural abortion at less than 10 weeks' gestation: A randomized controlled trial.

OBJECTIVES: This study aimed to compare satisfaction with procedural abortion prior to 10 weeks' gestation in patients randomized to lavender essential oil aromatherapy vs placebo (jojoba oil). STUDY DESIGN: This randomized trial compared lavender aromatherapy vs placebo in patients undergoing procedural abortion <10 weeks' gestation. Participants self-administered and inhaled oil during their procedures. Our primary outcome was composite mean score on the Iowa Satisfaction with Anesthesia Scale. Participants completed the State-Trait Anxiety Inventory, a visual analog scale reporting maximum procedural pain, and reported postprocedure aromatherapy acceptability. RESULTS: We analyzed 112 participants randomized to aromatherapy (n = 57) vs placebo (n = 55). Baseline characteristics were similar between groups. We found no difference in overall satisfaction (mean Iowa Satisfaction with Anesthesia Scale scores aromatherapy: 0.72 ± 0.96 vs placebo: 0.46 ± 0.98, p = 0.17) or maximum procedural pain (median visual analog scale score aromatherapy: 65 [range: 4-95] vs placebo: 63 [range: 7-97], p = 0.91). Independent predictors of satisfaction included the use of oral sedation (B: 0.36; 95% CI: 0.04-0.69), state anxiety (B: -0.45; 95% CI: -0.79 to -0.10), and maximum procedural pain (B: -0.17; 95% CI: -0.25 to -0.09). The aromatherapy participants were significantly more likely to have found inhaling scented oil helpful during their procedure (71.9% vs 45.5%; p = 0.005) and would recommend it to a friend who needed a procedural abortion (86.0% vs 56.4%; p = 0.0005) compared to those in the placebo group. Additionally, patients in the aromatherapy group were significantly more likely to agree with the statement, "If I need another procedural abortion, I would want to inhale scented oil during my procedure" (87.7% vs 70.9%; p = 0.03). CONCLUSIONS: The adjunctive use of lavender aromatherapy during first-trimester procedural abortion does not improve satisfaction with anesthesia but is highly valued by patients. IMPLICATIONS: Oral opioids as an adjunct to standard analgesics during procedural abortion (ibuprofen and paracervical block) do not decrease pain, and nonopioid options are lacking. Given current limited anesthesia options, aromatherapy could serve as an affordable and acceptable nonopioid adjunct to current standard of care during procedural abortion. GOV IDENTIFIER: NCT04969900.

Is it an abortion: Classification of pregnancy-ending interventions after 24 weeks in the presence of lethal fetal anomalies.

OBJECTIVES: To determine how obstetrician-gynecologists categorize pregnancy-ending interventions in the setting of lethal fetal anomalies. STUDY DESIGN: We conducted a sequential explanatory mixed-methods study of U.S. obstetrician-gynecologists from May to July 2021. We distributed a cross-sectional online survey via email and social media and completed qualitative telephone interviews with a nested group of participants. We assessed institutional classification as induced abortion versus indicated delivery for six scenarios of ending a pregnancy with lethal anomalies after 24 weeks, comparing classification using McNemar chi-square tests with Benjamini-Hochberg correction for multiple comparisons with a false discovery rate of 0.05. We performed the thematic analysis of qualitative data and then performed a mixed-methods analysis. RESULTS: We included 205 respondents; most were female (84.4%), had provided abortion care (80.2%), and were general OB/GYNs (59.3%), with broad representation across pre-Dobbs state and institutional abortion policies. Twenty-one qualitative participants had similar characteristics to the whole sample. All scenarios were classified as induced abortion by the majority of respondents, ranging from 53.2% for 32-week induction for anencephaly, to 82.9% for feticidal injection with 24-week induction for anencephaly. Mixed-methods analysis revealed the relevance of gestational age (later interventions less likely to be considered induced abortion) and procedure method and setting (dilation and evacuation, feticidal injection, and freestanding facility all increasing classification as induced abortion). CONCLUSIONS: There is wide variation in the classification of pregnancy-ending interventions for lethal fetal anomalies, even among trained obstetrician-gynecologists. Method, timing, and location of ending a nonviable pregnancy influence classification, though the perinatal outcome is unchanged. IMPLICATIONS: The classification of pregnancy-ending interventions for lethal fetal anomalies after 24 weeks as indicated delivery versus induced abortion is reflective of sociopolitical regulatory factors as opposed to medical science. The regulatory requirement for classification negatively impacts access to care, especially in environments where induced abortion is legally restricted.

The association of patient age, race, and demographic features on reported pain and sedation dosing during procedural abortion: A retrospective cohort study.

OBJECTIVES: To explore impact of age, racial, demographic, and psychosocial factors on patients' dosage of analgesia and maximum pain score during procedural abortion. STUDY DESIGN: We performed retrospective chart review of pregnant individuals undergoing procedural abortion at our hospital-based abortion clinic from October 2019 through May 2020. Patients were stratified into age groups,<19 years, 19 to 35 years, and>35 years. We conducted the Kruskal-Wallis H test to evaluate for medication dosing or maximum pain score differences among groups. RESULTS: We included 225 patients in our study. We found no difference in fentanyl or midazolam dosing by age. The median fentanyl dose was 75 mcg and median midazolam dose was 2 mg in all three groups (p = 0.61, p = 0.99). White patients received higher median midazolam dosing than Black patients (2 and 3 mg, respectively, p < 0.01) despite similar pain scores. Despite no difference in pain scores, patients terminating for genetic anomaly received more fentanyl than those terminating for socioeconomic reasons (75 and 100 mcg, respectively, p < 0.01). CONCLUSIONS: In our limited study, we found that White race and induced abortion for genetic anomaly were associated with increased medication dosing, though age was not. Multiple demographic and psychosocial factors, as well as perhaps provider bias, play into both a patient's perception of pain and the dosage of fentanyl and midazolam they receive during abortion procedures. IMPLICATIONS: By acknowledging both patient factors and provider biases in medication dosing, we can provide more equitable abortion care.

Fear of procedure and pain in individuals considering abortion: A qualitative study.

OBJECTIVES: To explore concerns about procedural abortion and abortion-related pain in a cohort searching for abortion online. METHODS: The Google Ads Abortion Access Study was a national longitudinal cohort study that recruited people searching for abortion online. Participants completed a baseline demographic survey and a follow-up survey four weeks later evaluating barriers and facilitators to abortion. This qualitative study utilized thematic analysis to produce a descriptive narrative based on overarching themes about procedural abortion and abortion-related pain. RESULTS: There were 57 separate mentions from 45 participants regarding procedural abortion or abortion-related pain. We identified two main themes: 1) concerns about the procedure (with subthemes, fear of procedural abortion, comparison to medication abortion, lack of sedation) and 2) abortion-related pain (with subthemes fear of abortion-related pain, experiences of pain, fear of complications and cost-barriers to pain control). CONCLUSIONS: This study highlights the need for improved anticipatory guidance and accessible resources to assuage potential fears and misconceptions regarding abortion. PRACTICE IMPLIACTIONS: Abortion resources, particularly online, should provide accurate and unbiased information about abortion methods and pain to help patients feel more prepared. Providers should be aware of potential concerns surrounding procedural abortion and pain when counseling patients presenting for care.

Classification of periviable pregnancy-ending interventions for maternal life endangerment as induced abortion.

OBJECTIVES: To explore how US obstetrician-gynecologists (OB/GYNs) classify periviable pregnancy-ending interventions for maternal life endangerment. STUDY DESIGN: From May to July 2021, we performed an explanatory sequential mixed methods study of US OB/GYNs, recruited through social media and professional listservs. We administered a cross-sectional survey requesting institutional classification of labor induction or surgical evacuation of a 22-week pregnancy affected by intrauterine infection, using chi-square tests and logistic regression to compare determinations by physician and institutional factors. We then conducted semistructured interviews in a diverse nested sample to explore decision-making, merging quantitative and qualitative data in a mixed methods analysis. RESULTS: We received 209 completed survey responses, with 101 (48.3%) current abortion providers and 48 (20.1%) never-providers, and completed 21 qualitative interviews. Fewer than half of respondents reported that pregnancy-ending intervention for 22-week intrauterine infection would be classified as induced abortion at their institution (induction: 21.1%, dilation & evacuation: 42.6%, p < 0.001). In addition to procedure method, decision-making factors for classification as abortion included personal experience with abortion (with more experienced participants more likely to identify care as abortion) and state and institutional abortion regulations ("I have to call it a medical [induction]… I'm not allowed to use the word abortion"). CONCLUSIONS: Most OB/GYNs do not classify periviable pregnancy-ending interventions for life-threatening maternal complications as induced abortion, especially when physicians and institutions have less abortion expertise. Differential classification of pregnancy-ending care may lead to undercounting of later abortion procedures, masking the impact of abortion restrictions. IMPLICATIONS: Under unclear legal definitions, legislative interference, and administrative overreach, subjectivity in classification creates inconsistency in care for pregnancy complications. Failure to classify life-saving care as abortion contributes to stigma and facilitates restrictions, with increased danger and less autonomy for pregnant people.

Society of Family Planning clinical recommendations: Management of individuals with bleeding or thrombotic disorders undergoing abortion.

Individuals who have bleeding disorders, thrombophilias, a history of venous thromboembolism (VTE), or who are taking anticoagulation medication for other reasons may present for abortion. Clinicians should be aware of risk factors and histories concerning for excessive bleeding and thrombotic disorders around the time of abortion. This document will focus on how to approach abortion planning in these individuals. For first-trimester abortion, procedural abortion (sometimes called surgical abortion) is generally preferred over medical management for individuals with bleeding disorders or who are on anticoagulation. First-trimester procedural abortion in an individual on anticoagulation can generally be done without interruption of anticoagulation. The decision to interrupt anticoagulation for a second-trimester procedure should be individualized. Individuals at high risk for VTE can be offered anticoagulation post-procedure. Individuals with bleeding disorders or who are anticoagulated can safely be offered progestin intrauterine devices. Future research is needed to better assess quantitative blood loss and complications rates with abortion in these populations.