Safety of deep sedation without intubation during surgical abortion in the independent clinic setting.

OBJECTIVE: To establish the safety of deep sedation without intubation delivered by a certified registered nurse anesthetist (CRNA) in an independent outpatient abortion setting. STUDY DESIGN: We performed a review of clinic Quality and Patient Safety Reports, a daily-maintained report of complications at time of all dilation and curettage (D&C) and dilation and evacuation (D&E) procedures performed at an independently operated, urban, high-volume abortion clinic between March 2013 and August 2017. The clinic provided procedures through 23 weeks 6 days gestation to women at low risk for medical or surgical complications, referring high-risk procedures to a nearby hospital. A CRNA provided anesthesia for all deep sedation procedures. We extracted information on gestational age, risk factors, and clinical course for all patients who experienced any anesthesia-related complication. RESULTS: During the study period, the clinic evaluated 10,297 women for surgical abortion, referring 292 high-risk cases and performing 10,005 procedures (9004 D&C and 1001 D&E), most (9405 [94%]) with deep sedation. We documented six anesthesia-related complications; three (0.03%) in D&C procedures (laryngospasm not requiring intubation [n = 2] and respiratory stridor) and three (0.30%) in D&E procedures (laryngospasm requiring intubation, seizure, and hypotension/bradycardia). Only one patient (0.01%) required intubation. CONCLUSIONS: Anesthesia-related complications in the setting of deep sedation without intubation during surgical abortion were exceedingly rare, supporting the safety of this form of anesthesia for low-risk patients in an independent community clinic setting. IMPLICATIONS: Independent community clinics, where the majority of abortion procedures are performed within the U.S., can provide safe anesthesia care using deep sedation provided by CRNA professionals. This care delivery model, which includes triaging patient eligibility, reassuringly provides anesthesia as safely as other greater resourced care delivery settings.

Global hypermethylation in fetal cortex of Down syndrome due to DNMT3L overexpression.

Down syndrome (DS) is caused by a triplication of chromosome 21 (HSA21). Increased oxidative stress, decreased neurogenesis and synaptic dysfunction from HSA21 gene overexpression are thought to cause mental retardation, dementia and seizure in this disorder. Recent epigenetic studies have raised the possibility that DNA methylation has significant effects on DS neurodevelopment. Here, we performed methylome profiling in normal and DS fetal cortices and observed a significant hypermethylation in ∼4% of probes in the DS samples compared with age-matched normals. The probes with differential methylation were distributed across all chromosomes, with no enrichment on HSA21. Functional annotation and pathway analyses showed that genes in the ubiquitination pathway were significantly altered, including: BRCA1, TSPYL5 and PEX10 HSA21 located DNMT3L was overexpressed in DS neuroprogenitors, and this overexpression increased the promoter methylation of TSPYL5 potentially through DNMT3B, and decreased its mRNA expression. DNMT3L overexpression also increased mRNA levels for TP53 and APP, effectors of TSPYL5 Furthermore, DNMT3L overexpression increased APP and PSD95 expression in differentiating neurons, whereas DNMT3LshRNA could partially rescue the APP and PSD95 up-regulation in DS cells. These results provide some of the first mechanistic insights into causes for epigenetic changes in DS, leading to modification of genes relevant for the DS neural endophenotype.

Uterine artery embolization to treat hemorrhage following second-trimester abortion by dilatation and surgical evacuation.

BACKGROUND: This study was conducted to review cases of second-trimester postabortal hemorrhage (PAH) occurring at a private women's health facility that were treated with uterine artery embolization (UAE). METHODS: A retrospective review was conducted on all second-trimester terminations performed at a private women's health facility between 1999 and 2006. Cases of PAH treated with UAE were reviewed in detail, reviewing progress, operative and discharge notes along with anesthesia records. RESULTS: Fifteen cases of PAH were identified among 3936 second-trimester terminations that were performed. Seven cases were identified in which UAE was used to treat PAH. Etiologies leading to hemorrhage varied in the seven cases as did the presence of coexisting factors such as infection and anatomic lesions. All cases were successfully treated by UAE, requiring no additional surgical intervention. CONCLUSION: Given the success of embolization, we offer this as an alternative to exploratory surgery and hysterectomy and as a first-line approach in cases of PAH after conservative management strategies have failed.