A Case of an Obstructed Delivery by a Large, Lower Uterine Segment Fibroid Interlocked with a Fetal Mentum.

Uterine leiomyomata are associated with many pregnancy complications and will likely become increasingly common as the average age of childbearing increases. We describe a case of an obstructed delivery by a large fibroid. A 37-year-old G2P1001 with a 10-cm anterior, lower uterine segment fibroid presented for labor induction. Labor was complicated by arrest of descent due to suspected obstruction of the fetal body by the fibroid after descent of the fetal head, and delivery during cesarean section was complicated by apparent interlocking of the fetal mentum with the fibroid. Large, anterior lower uterine segment fibroids have the potential to obstruct delivery of the fetal head or of the fetal body, and these patients should be counseled regarding the potential for complications via both vaginal and cesarean deliveries.

Prior Cesarean Birth and Risk of Uterine Rupture in Second-Trimester Medication Abortions Using Mifepristone and Misoprostol: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess the risk difference of uterine rupture when using current mifepristone and misoprostol regimens for second-trimester abortion among individuals with prior cesarean birth compared with those without prior cesarean birth. DATA SOURCES: We searched the terms second trimester, induction, mifepristone, and abortion in PubMed, EMBASE, POPLINE, ClinicalTrials.gov , and Cochrane Library from inception until December 2022. METHODS OF STUDY SELECTION: We included randomized trials and observational studies including a mixed cohort, with and without uterine scar, of individuals at 14-28 weeks of gestation who used mifepristone and misoprostol to end a pregnancy or to manage a fetal death. We excluded case reports, narrative reviews, and studies not published in English. Two reviewers independently screened studies. TABULATION, INTEGRATION, AND RESULTS: Absolute risks with binomial CIs were calculated from pooled data. Using R software, we estimated total risk difference by the Mantel-Haenszel random-effects method without continuity correction. For studies with zero events, a continuity correction of 0.5 was applied for individual risk differences and plotted graphically with forest plots. Statistical heterogeneity was assessed with Higgins I2 statistics. Funnel plot assessed for publication bias. Of 198 articles identified, 22 met the inclusion criteria: seven randomized trials (n=923) and 15 observational studies (n=6,195). Uterine rupture risk with prior cesarean birth was 1.1% (10/874) (95% CI 0.6-2.1) and without prior cesarean birth was 0.01% (2/6,244) (95% CI 0.0-0.12). The risk difference was 1.23% (95% CI 0.46-2.00, I2 =0%). Of the 12 reported uterine ruptures, three resulted in hysterectomy. CONCLUSION: Uterine rupture with mifepristone and misoprostol use during second-trimester induction abortion is rare, with the risk increased to 1% in individuals with prior cesarean birth. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022302626.

Cervical preparation for second-trimester procedural abortion.

PURPOSE OF REVIEW: To review the evidence-informed options for cervical preparation prior to second-trimester dilation and evacuation (D&E). RECENT FINDINGS: As abortion restrictions increase and the number of abortion clinics and providers decreases, pregnant people are facing more barriers to abortion access. Those in need are now often required to travel for second-trimester abortion care, only to be faced with additional restrictions, such as mandatory waiting periods. Cervical preparation is recommended prior to D&E and takes time for effect. Given the increasing time required to obtain an abortion, patients and providers may prefer same-day cervical preparation to decrease the total time required. Options for same-day cervical preparation include misoprostol alone with single or serial doses, and misoprostol combined with osmotic dilators or transcervical balloon (Foley catheter). Same-day preparation may require additional clinical space to accommodate people after initiation of cervical preparation to manage side-effects and timing of the abortion. Overnight options are also used and more frequently later in the second trimester. Overnight options include mifepristone, osmotic dilators, and transcervical balloon and are often combined with same-day misoprostol. Medication alone preparation is well tolerated and effective in the second trimester, with the addition of mechanical methods with advancing gestation. With many options and combinations being safe and effective, providers can be dynamic and alter approach with supply shortages, adjust to different clinical settings, consider patient medical and surgical factors, and accommodate provider and patient preferences. SUMMARY: Multiple pharmacologic and mechanical options have been shown to be safe and effective for cervical preparation prior to D&E. Consideration for multiple factors should influence the method of cervical preparation and methods may vary by patient, provider and setting.

Cabergoline for Lactation Inhibition After Second-Trimester Abortion or Pregnancy Loss: A Randomized Controlled Trial.

OBJECTIVE: To assess cabergoline's efficacy at decreasing breast symptoms after second-trimester abortion or pregnancy loss. METHODS: This was a double-blinded, block-randomized superiority trial comparing cabergoline 1 mg once to placebo for preventing bothersome breast engorgement after second-trimester uterine evacuation. We enrolled pregnant people at 18-28 weeks of gestation who were English- or Spanish-speaking and without contraindication to the study drug. Participants completed a validated, piloted, electronic survey at baseline and at multiple timepoints through 2 weeks postprocedure to assess breast symptoms, side effects, and bother. Our primary outcome was any breast symptoms (a composite of engorgement, milk leakage, tenderness, and need for pain relief) on day 4; we planned to enroll 80 patients to show a 30% difference in breast symptoms (80% power, α=0.049). A subgroup of participants returned for serum prolactin levels. RESULTS: After screening 150 patients from April 2021 to June 2022, we enrolled 73 participants. Baseline demographics were balanced between groups: median gestational age was 21 weeks (range 18-26 weeks), 56.2% of participants were nulliparous, 34.2% self-identified as Hispanic, and 37.0% had public insurance. At baseline, reported breast symptoms were similar between groups. Among 69 participants who returned surveys on day 4, significantly fewer participants receiving cabergoline reported any breast symptoms compared with placebo (27.8% vs 97.0%, P<.001) (primary outcome) and fewer reported significant bother (2.8% vs 33.3%, P=.001) (secondary outcome). These differences persisted through day 14. Reported incidence and severity of bother from side effects were similar between groups: most common were constipation, fatigue, and headache. Serum prolactin levels were similar at baseline. On day 4, mean serum prolactin level was 6.5 ng/mL (SD 2.2) for those who received cabergoline and 18.0 ng/mL (SD 5.9) for placebo (P=.049). CONCLUSION: Cabergoline is an effective and well-tolerated strategy to prevent breast symptoms after second-trimester abortion or pregnancy loss. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT04701333.

Postpartum long-acting reversible contraceptive use among active-duty, female US Army soldiers.

BACKGROUND: Postpartum use of long-acting reversible contraception has been found to be effective at increasing interpregnancy intervals, reducing unintended pregnancies, and optimizing health outcomes for mothers and babies. Among female active-duty military service members, reproductive planning may be particularly important, yet little is known about postpartum long-acting reversible contraceptive use among active-duty soldiers. OBJECTIVE: This study aimed to (1) quantify postpartum uptake of long-acting reversible contraception among active-duty female US Army soldiers and (2) identify demographic and military-specific characteristics associated with use. STUDY DESIGN: This retrospective cohort study used longitudinal data of all digitally recorded health encounters for active-duty US Army soldiers from 2014 to 2017. The servicewomen included in our analysis were aged 18 to 44 years with at least one delivery and a minimum of 4 months of total observed time postdelivery within the study period. We defined postpartum long-acting reversible contraception use as initiation of use within the delivery month or in the 3 calendar months following delivery and identified likely immediate postpartum initiation via the proxy of placement recorded during the same month as delivery. We then evaluated predictors of postpartum long-acting reversible contraception use with multivariable logistic regression. RESULTS: The inclusion criteria were met by 15,843 soldiers. Of those, 3162 (19.96%) initiated the use of long-acting reversible contraception in the month of or within the 3 months following delivery. Fewer than 5% of these women used immediate postpartum long-acting reversible contraception. Among women who initiated postpartum long-acting reversible contraceptive use, 1803 (57.0%) received an intrauterine device, 1328 (42.0%) received an etonogestrel implant, and 31 received both (0.98%). Soldiers of younger age, self-reported White race, and those who were married or previously married were more likely to initiate long-acting reversible contraception in the postpartum period. Race-stratified analyses showed that self-reported White women had the highest use rates overall. When compared with these women, the adjusted odds of postpartum use among self-reported Black and Asian or Pacific Islander women were 18% and 30% lower, respectively (both P<.001). There was also a trend of decreasing postpartum use with increasing age within each race group. Differences observed between age groups and race identities could partially be attributed to differential use of permanent contraception (sterilization), which was found to be significantly more prevalent among both women aged 30 years or older and among women who identified as Black. CONCLUSION: Among active-duty US Army servicewomen, 1 in 5 used postpartum long-acting reversible contraception, and fewer than 5% of these women used an immediate postpartum method. Within this population with universal healthcare coverage, we observed relatively low rates of use and significant differences in the uptake of effective postpartum long-acting contraceptive methods across self-reported race categories.

Postpartum long-acting reversible contraception among privately insured: U.S. National analysis 2007-2016, by term and preterm birth.

OBJECTIVES: To investigate postpartum long-acting reversible contraception (LARC) use among privately insured women, with specific consideration of use after preterm delivery. STUDY DESIGN: We used the national IBM MarketScan Commercial Database to identify singleton deliveries from 2007 to 2016, spontaneous preterm birth, and follow-up ≤12 weeks postpartum. We assessed ≤12-week postpartum LARC placement overall and after spontaneous preterm deliveries, across study years. We examined timing of placement, rates of postpartum follow-up, and state-level variation in postpartum LARC. RESULTS: Among 3,132,107 singleton deliveries, 6.6% were spontaneous preterm. Over the time period, total postpartum LARC use increased 4.8% to 11.7% for intrauterine devices (IUDs), 0.2% to 2.4% for implants. In 2016, those who experienced a spontaneous preterm birth were less likely to initiate postpartum IUDs compared to their peers (10.2% vs 11.8%, p < 0.001), minimally more likely to initiate implants (2.7% vs 2.4%, p = 0.04) and more likely to present for postpartum care (61.7% vs 55.9%, p < 0.001). LARC placement prior to hospital discharge was rare (preterm: 8 per 10,000 deliveries vs all others: 6.3 per 10,000 deliveries, p = 0.002). State-level analysis showed wide variation in postpartum LARC (range 6%-32%). CONCLUSIONS: While postpartum LARC use increased among the privately insured 2007-2016, few received LARC prior to hospital discharge. Those experiencing preterm birth were no more likely to receive inpatient LARC. Postpartum follow-up remained low and regional variation of LARC was high, highlighting the need for efforts to remove barriers to inpatient postpartum LARC for all who desire it-public and privately insured alike. IMPLICATIONS: Among the half of U.S. births that are privately insured, postpartum LARC is increasing after both term and preterm births, yet exceedingly few (<0.1%) received LARC prior to hospital discharge.

Anesthetic Considerations for Second-Trimester Surgical Abortions.

Although most abortion care takes place in the office setting, anesthesiologists are often asked to provide anesthesia for the 1% of abortions that take place later, in the second trimester. Changes in federal and state regulations surrounding abortion services may result in an increase in second-trimester abortions due to barriers to accessing care. The need for interstate travel will reduce access and delay care for everyone, given limited appointment capacity in states that continue to support bodily autonomy. Therefore, anesthesiologists may be increasingly involved in care for these patients. There are multiple, unique anesthetic considerations to provide safe and compassionate care to patients undergoing second-trimester abortion. First, a multiday cervical preparation involving cervical osmotic dilators and pharmacologic agents results in a time-sensitive, nonelective procedure, which should not be delayed or canceled due to risk of fetal expulsion in the preoperative area. In addition, a growing body of literature suggests that the older anesthesia dogma that all pregnant patients require rapid-sequence induction and an endotracheal tube can be abandoned, and that deep sedation without intubation is safe and often preferable for this patient population through 24 weeks of gestation. Finally, concomitant substance use disorders, preoperative pain from cervical preparation, and intraoperative management of uterine atony in a uterus that does not yet have mature oxytocin receptors require additional consideration.

New Gaps and Urgent Needs in Graduate Medical Education and Training in Abortion.

Abortion is essential health care, and abortion training and education are essential at all levels of medical education. Among the most common procedures performed in obstetrics and gynecology (OB/GYN), abortion is a core competency for OB/GYN residency programs. For nearly 50 years, the procedure was federally protected by the U.S. Supreme Court's January 22, 1973, Roe v Wade decision. On June 24, 2022, amidst increasing state restrictions limiting abortion access, the Court's decision on Dobbs v Jackson Women's Health Organization effectively reversed Roe . As a result, immediate bans on abortion went into effect across the country, removing access to abortion for millions of people and newly limiting training and education in this core competency for many medical residents. As of June 2022, nearly half of U.S. OB/GYN residency programs and more than 40% of residents are located in states that have banned or are likely to ban abortion. In states where abortion is restricted or illegal, states must adapt quickly to ensure their residents meet training requirements. This adaptation may include developing and leveraging relationships with programs in states where access is protected, depending on simulation, and placing greater emphasis on education and training in pregnancy loss management and postabortion care. None of these is a comprehensive solution and even all together, they are insufficient to train residents and medical students. Ultimately, many future physicians will not receive the training they need to provide full reproductive health care to their pregnant patients. Legal and other systems of support are needed to ensure that current and future physicians can provide compassionate, evidence-based reproductive health care, including essential abortion care.

Lactogenesis and breastfeeding after immediate vs delayed birth-hospitalization insertion of etonogestrel contraceptive implant: a noninferiority trial.

BACKGROUND: Initiating a progestin-based contraceptive before the drop in progesterone required to start lactogenesis stage II could theoretically affect lactation. Previous studies have shown that initiating progestin-based contraception in the postnatal period before birth-hospitalization discharge has no detrimental effects on breastfeeding initiation or continuation compared with outpatient interval initiation. However, there are currently no breastfeeding data on the impact of initiating the etonogestrel contraceptive implant in the early postnatal period immediately in the delivery room. OBJECTIVE: This study examined the effect of delivery room vs delayed birth-hospitalization contraceptive etonogestrel implant insertion on breastfeeding outcomes. STUDY DESIGN: This was a noninferiority randomized controlled trial to determine if time to lactogenesis stage II (initiation of copious milk secretion) differs by timing of etonogestrel implant insertion during the birth-hospitalization. We randomly assigned pregnant people to insertion at 0 to 2 hours (delivery room) vs 24 to 48 hours (delayed) postdelivery. Participants intended to breastfeed, desired a contraceptive implant for postpartum contraception, were fluent in English or Spanish, and had no allergy or contraindication to the etonogestrel implant. We collected demographic information and breastfeeding intentions at enrollment. Onset of lactogenesis stage II was assessed daily using a validated tool. The noninferiority margin for the mean difference in time to lactogenesis stage II was defined as 12 hours in a per-protocol analysis. Additional electronic surveys collected data on breastfeeding and contraceptive continuation at 2 and 4 weeks, and 3, 6, and 12 months. RESULTS: We enrolled and randomized 95 participants; 77 participants were included in the modified intention-to-treat analysis (n=38 in the delivery room group and n=39 in the delayed group) after excluding 18 because of withdrawing consent, changing contraceptive or breastfeeding plans, or failing to provide primary outcome data. A total of 69 participants were included in the as-treated analysis (n=35 delivery room, n=34 delayed); 8 participants who received the etonogestrel implant outside the protocol windows were excluded, and 2 participants from the delivery room group received the etonogestrel implant at 24 to 48 hours and were analyzed with the delayed group. Participants were similar between groups in age, gestational age, and previous breastfeeding experience. Delivery room insertion was noninferior to delayed birth-hospitalization insertion in time to lactogenesis stage II (delivery room [mean±standard deviation], 65±25 hours; delayed, 73±61 hours; mean difference, -9 hours; 95% confidence interval, -27 to 10). Onset of lactogenesis stage II by postpartum day 3 was not significantly different between the groups. Lactation failure occurred in 5.5% (n=2) participants in the delayed group. Ongoing breastfeeding rates did not differ between the groups, with decreasing rates of any/exclusive breastfeeding over the first postpartum year. Most people continued to use the implant at 12 months, which did not differ by group. CONCLUSION: Delivery room insertion of the contraceptive etonogestrel implant does not delay the onset of lactogenesis when compared with initiation later in the birth-hospitalization and therefore should be offered routinely as part of person-centered postpartum contraceptive counseling, regardless of breastfeeding intentions.

Addressing postpartum contraception practices utilizing a multidisciplinary Pregnancy Heart Team approach.

BACKGROUND: Cardiovascular disease has emerged as the leading cause of maternal morbidity and mortality, making planned pregnancy, and thereby reliable contraception among people with cardiovascular disease, vital. OBJECTIVE: This study aimed to compare postpartum contraceptive practices among people with cardiovascular disease (cardiac cohort) cared for by a Pregnancy Heart Team to people with other chronic comorbidities (high-risk cohort), and people without comorbidities (low-risk cohort). We hypothesized that the Pregnancy Heart Team influenced baseline contraception counseling and practices among those with cardiovascular disease. STUDY DESIGN: This was a retrospective cohort study comparing postpartum contraceptive practices between a cardiac cohort who received care by a multidisciplinary team between 2012 and 2020 and high-risk and low-risk cohorts delivering at a single academic center between 2016 and 2019. We investigated presence of a contraceptive plan (at birthing admission, discharge, and postpartum visit) and uptake of reliable contraception by 8 weeks postpartum. RESULTS: We included 1464 people: 189 with cardiovascular disease, 197 with other chronic comorbidities, and 1078 low-risk people. At birth hospitalization admission, reliable contraception was planned among 42% of the cardiac cohort, 40% of the high-risk cohort, and 31% of the low-risk cohort, with similar distributions at the time of discharge and at 8 weeks postpartum. Compared with the cardiac cohort, by 8 weeks postpartum, the high-risk cohort had similar odds of using highly reliable forms of contraception (39% vs 36%; adjusted odds ratio, 0.78; 95% confidence interval, 0.50-1.21) and similar odds of having a plan to use the most reliable forms of contraception (intrauterine device, implant, bilateral tubal ligation) at the time of birthing admission (42% vs 40%; adjusted odds ratio, 0.78; 95% confidence interval, 0.50-1.22), discharge (47% vs 45%; adjusted odds ratio, 0.95; 95% confidence interval, 0.61-1.48), and postpartum visit (35% vs 29%; adjusted odds ratio, 0.76; 95% confidence interval, 0.49-1.17). The low-risk cohort had lower odds of using a reliable form of contraception (39% vs 27%; adjusted odds ratio, 0.53; 95% confidence interval, 0.37-0.75) and was less likely to have a plan for reliable contraception at the time of birthing admission (42% vs 31%; adjusted odds ratio, 0.54; 95% confidence interval, 0.38-0.76), discharge (47% vs 33%; adjusted odds ratio, 0.58; 95% confidence interval, 0.4-0.82), and postpartum visit (35% vs 21%; adjusted odds ratio, 0.50; 95% confidence interval, 0.35-0.71). CONCLUSION: People with cardiovascular disease cared for by a Pregnancy Heart Team had higher odds of reliable postpartum contraception planning and uptake compared with a low-risk cohort and similar odds compared with a high-risk cohort. Pregnancy could serve as a critical period for contraception counseling and family planning among people with cardiovascular disease. A multidisciplinary team should be used to address postpartum contraception as a modifiable risk factor to reduce maternal morbidity and mortality among those with cardiovascular disease.

Impact of a Potential 20-Week Abortion Ban on Likelihood of Completing Required Views in Second-Trimester Fetal Anatomy Ultrasound.

OBJECTIVE: The aim of this study was to quantify the likelihood of assessing all mandated fetal views during the second-trimester anatomy ultrasound prior to the proposed federal 20-week abortion ban. STUDY DESIGN: Retrospective cohort study of a random sample of 1,983 patients undergoing anatomy ultrasound in 2017 at a tertiary referral center. The difference in proportion of incomplete anatomic surveys prior compared with after 20-week gestation was analyzed using X 2 and adjusted logistic regression; difference in mean days elapsed from anomaly diagnosis to termination tested using t-tests and survival analysis. RESULTS: Incomplete views were more likely with initial ultrasound before 20 weeks (adjusted relative risk: 1.70; 95% confidence interval: 1.50-1.94); 43.5% versus 26.1% were incomplete before and after 20 weeks, respectively. Fetal structural anomalies were identified in 6.4% (n = 127/1,983) scans, with 38.0% (n = 49) identified at follow-up after initial scan was incomplete. 22.8% (n = 29) with an anomaly terminated. CONCLUSIONS: A complete assessment of fetal views during an anatomy ultrasound prior to 20-week gestation is often not technically feasible. Legislation limiting abortion to this gestational age would greatly impact patient's ability to make informed choices about their pregnancies. KEY POINTS: · It is often not technically possible to complete anatomy ultrasound prior to 20-week gestation.. · Often, anomalies are missed during early, incomplete anatomy ultrasounds.. · After the diagnosis of a structural anomaly, one in five chose to terminate the pregnancy..

Potential candidate for oral pericoital contraception: evaluating ulipristal acetate plus cyclo-oxygenase-2 inhibitor for ovulation disruption.

BACKGROUND: There remains considerable global unmet contraceptive need, with almost 200 million women reporting desire to limit or space childbearing without contraceptive use. Researchers have documented worldwide interest in an oral, on-demand contraceptive option were it available. Candidates for use include ulipristal acetate (UA), levonorgestrel and cyclo-oxygenase-2 (COX-2) inhibitors alone or in combination. METHODS: We performed an exploratory, prospective study of matched menstrual cycles: one baseline cycle and one treatment cycle of UA 30 mg plus meloxicam 30 mg just prior to ovulation. The primary outcome was ovulation disruption, defined as unruptured dominant follicle for 5 days. Secondary outcomes included comparing cycle length, endometrial stripe thickness, and side effects. RESULTS: Nine participants completed all study procedures in both cycles. Ovulatory disruption occurred in 66.7% (n=6) of treatment cycles and all but one demonstrated features of ovulatory dysfunction. Cycle length (mean±SD) was longer in the treatment cycle (31.9±4.0 vs 28.6±3.5 days, p<0.01). Secondary outcomes did not differ between the two cycles. CONCLUSIONS: UA plus the COX-2 inhibitor meloxicam disrupts ovulation at peak luteal surge and is a promising candidate for evaluation as a pericoital oral contraceptive. TRIAL REGISTRATION NUMBER: NCT03354117.

Making the financial case for immediate postpartum intrauterine device: a budget impact analysis.

BACKGROUND: Clinical guidelines support inpatient postpartum intrauterine device insertion. However, inpatient placement remains infrequent, in part because of inconsistent private insurance reimbursement. OBJECTIVE: The purpose of this study was to explore how the payer's costs and number of unintended pregnancies associated with a postpartum intrauterine device differed on the basis of placement timing. STUDY DESIGN: Using a decision tree model and following a hypothetical cohort of people who intend to use an intrauterine device after their delivery, we conducted a cost analysis comparing the planned approach of inpatient vs outpatient postpartum insertion. Using a 2-year time horizon, the probability and cost estimates were derived from literature review. Our primary outcome was the total accrued costs to the payer. Secondarily, we examined the rates of early repeat pregnancy and sensitivity to estimates of key inputs, including the expulsion rates and the intrauterine device cost. RESULTS: Although an inpatient intrauterine device placement's upfront costs were higher, the total cost of this approach was lower. Including the costs of managing expulsions and complications, our model suggests that for every 1000 people desiring a postpartum intrauterine device, the intended inpatient intrauterine device placement resulted in total cost savings of $211,100 and the prevention of 37 additional pregnancies compared with outpatient placement. The inpatient cost savings were superior to the outpatient savings, largely because of a known high proportion not returning for outpatient placement and the resulting higher number of unintended pregnancies among the patients desiring outpatient placement. In sensitivity analyses, we found that the total cost to the payer was sensitive to the probability of expulsion after immediate postpartum intrauterine device placement. CONCLUSION: For beneficiaries desiring postpartum intrauterine device, payers are likely to save money by fully reimbursing inpatient intrauterine device placement rather than incentivizing placement at the frequently missed postpartum visit. These results support the financial case for private insurers to fully and separately reimburse (ie, "unbundle" from the single payment for delivery) inpatient postpartum intrauterine device placement.

Pain management in outpatient surgical abortion.

PURPOSE OF REVIEW: To review the current literature focusing on pain management and experiences during abortion care. RECENT FINDINGS: Analgesic options in abortion care address pain associated with the procedure, osmotic dilator insertion, and cervical preparation. The paracervical block (PCB) is effective for pain control in first and second trimester abortions. Lower volume PCBs demonstrate non inferiority with osmotic dilator placement compared with higher volume PCBs with lower potential for toxicity. Self-administered vaginal lidocaine gel is noninferior to PCB in first trimester abortions. Preoperative oral narcotics and sedation do not reduce pain in first trimester abortions; however, the latter may reduce anxiety. For second trimester abortions, narcotics or gabapentin do not improve postoperative pain, yet up to half of patients will use narcotics if offered. Nonpharmacological methods have shown success in pain management. Music and doula support do not improve pain; however, patients would recommend these modalities, indicating some benefit that went unmeasured. Auricular acupuncture and transcutaneous electrical nerve stimulation (TENS) reduce pain and anxiety during first trimester abortions. SUMMARY: Several modalities reduce pain during abortion care; however, pain alone does not reflect patient satisfaction. Development of multidimensional measures for pain control assessment has the potential to capture the patient's overall experience.

A Comparison of Paracervical Block Volumes Before Osmotic Dilator Placement: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether a 12-mL paracervical block is noninferior to a 20-mL block in reducing pain with osmotic dilator insertion. METHODS: In this single-blinded noninferiority trial, we randomized individuals undergoing insertion of osmotic dilators before second-trimester abortion to receive either a 12-mL or 20-mL 1% lidocaine paracervical block. The primary outcome was pain immediately after insertion of osmotic dilators. Prespecified secondary outcomes included pain with paracervical block administration, overall pain, and side effects, with 88 participants being required for a noninferiority margin of 15 mm on a 100-mm visual analog scale assuming an SD of 28. We analyzed data using Wilcoxon rank sum, χ2, and t tests and performed analysis of variance to account for repeated measures. Secondary analysis included multivariable regression to explore potential confounders. RESULTS: From January 2018 to October 2020, of 232 eligible individuals, 174 were approached and 96 randomized (48 participants to each group); 91 were available for analysis (45: 12 mL, 46: 20 mL). Group demographics were similar, with a mean gestation of 21 weeks and four osmotic dilators placed. The 12-mL paracervical block was noninferior to the 20-mL paracervical block for pain with osmotic dilator insertion with a difference in means of -1.36 (95% CI -12.56 to 9.85) favoring 12 mL. Median pain scores after dilator placement were 47 mm (interquartile range 22-68) and 50 mm (interquartile range 27-67) in 12-mL compared with 20-mL paracervical block, respectively (P=.81). No difference was seen in median pain at baseline, with paracervical block administration, postprocedure or with overall pain or experience. At least one lidocaine-related side effect occurred in 4% of participants in the 12-mL group compared with 13% for those receiving 20 mL (P=.15), with metallic taste, ringing in ears, and lightheadedness being most common. CONCLUSION: A 12-mL paracervical block is noninferior to a 20-mL block for pain reduction with osmotic dilator insertion. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03356145.

Transcutaneous Electrical Nerve Stimulation for Pain Management of Aspiration Abortion up to 83 Days of Gestation: A Randomized Controlled Trial.

OBJECTIVE: To evaluate high-frequency, high-intensity transcutaneous electrical nerve stimulation (TENS) as an inexpensive, noninvasive pain management approach for first-trimester aspiration abortion. METHODS: We conducted a noninferiority, single-blind, randomized controlled trial of patients seeking aspiration abortion at up to 83 days of gestation. Participants received TENS (placed posteriorly, T10-L1 and S2-S4) or intravenous (IV) sedation (fentanyl, midazolam). The primary outcome was pain with aspiration, as self-reported by visual analog scale (VAS, 100 mm). To detect at least a 15 mm mean difference on the 100 mm VAS with 90% power and a significance level of .05, a total of 90 participants were required. RESULTS: Between January 2018 and October 2019, we enrolled 109 participants (55 TENS, 54 IV). Participant median gestation was 53 days (range 36-82) in the TENS group and 58 days (range 35-82) in the IV group (P=.65). Group demographics and clinical histories were similar. Intention-to-treat analysis (n=109) yielded noninferior results for the primary outcome (mean difference 4.8 mm, 95% CI -5.9 to 13.5 mm). In the per-protocol analysis, 9 (16%) in the TENS group were excluded after receiving IV sedation; 100 participants were included (46 TENS, 54 IV). Median (range) reported VAS for aspiration was 73 mm (13-97) and 66 mm (0-99) in the TENS and IV groups, respectively (P=.40). With a mean difference of 4.4 mm (95% CI -5.6 to 14.5 mm), we found TENS to be noninferior to IV. Physicians underestimated participant pain, perceiving pain to be 34 mm (6-91) in the TENS group and 25 mm (0-83) in the IV group (P=.003). CONCLUSION: We found TENS to be a noninferior alternative to IV sedation for aspiration pain during first-trimester abortion. Expanding pain management options can improve quality of and access to abortion. Transcutaneous electrical nerve stimulation could be a standalone or adjunct approach for abortion pain management for those without access to or are ineligible to receive IV sedation due to the lack of sedation practitioner, designated driver, or local restrictions. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03187002.

First Trimester Abortion Care in Low- and Middle-Income Countries.

Access to first trimester abortions has increased significantly in the past few decades in low and middle-income countries. Manual vacuum aspiration is now standard of care for procedural abortion and postabortion care. Medication abortion has shifted abortions to being performed earlier in pregnancy and is becoming more widely available with new service delivery strategies to broaden access. Widespread availability of misoprostol has made abortions induced outside of the formal medical sector overall safer. In both legally restrictive and supportive environments, there is increased interested in self-managed abortions as part of a shift towards demedicalizing abortion through task-sharing.