Mail-Order Pharmacy Dispensing of Mifepristone for Medication Abortion After In-Person Screening.

Importance: Before 2021, the US Food and Drug Administration required mifepristone to be dispensed in person, limiting access to medication abortion. Objective: To estimate the effectiveness, acceptability, and feasibility of dispensing mifepristone for medication abortion using a mail-order pharmacy. Design, Setting, and Participants: This prospective cohort study was conducted from January 2020 to May 2022 and included 11 clinics in 7 states (5 abortion clinics and 6 primary care sites, 4 of which were new to abortion provision). Eligible participants were seeking medication abortion at 63 or fewer days' gestation, spoke English or Spanish, were age 15 years or older, and were willing to take misoprostol buccally. After assessing eligibility for medication abortion through an in-person screening, mifepristone and misoprostol were prescribed using a mail-order pharmacy. Patients had standard follow-up care with the clinic. Clinical information was collected from medical records. Consenting participants completed online surveys about their experiences 3 and 14 days after enrolling. A total of 540 participants were enrolled; 10 withdrew or did not take medication. Data were analyzed from August 2022 to December 2023. Intervention: Mifepristone, 200 mg, and misoprostol, 800 µg, prescribed to a mail-order pharmacy and mailed to participants instead of dispensed in person. Main Outcomes and Measures: Proportion of patients with a complete abortion with medications only, reporting satisfaction with the medication abortion, and reporting timely delivery of medications. Results: Clinical outcome information was obtained and analyzed for 510 abortions (96.2%) among 506 participants (median [IQR] age, 27 [23-31] years; 506 [100%] female; 194 [38.3%] Black, 88 [17.4%] Hispanic, 141 [27.9%] White, and 45 [8.9%] multiracial/other individuals). Of these, 436 participants (85.5%; 95% CI, 82.2%-88.4%) received medications within 3 days. Complete abortion occurred after medication use in 499 cases (97.8%; 95% CI, 96.2%-98.9%). There were 24 adverse events (4.7%) for which care was sought for medication abortion symptoms; 3 patients (0.6%; 95% CI, 0.1%-1.7%) experienced serious adverse events requiring hospitalization (1 with blood transfusion); however, no adverse events were associated with mail-order dispensing. Of 477 participants, 431 (90.4%; 95% CI, 87.3%-92.9%) indicated that they would use mail-order dispensing again for abortion care, and 435 participants (91.2%; 95% CI, 88.3%-93.6%) reported satisfaction with the medication abortion. Findings were similar to those of other published studies of medication abortion with in-person dispensing. Conclusions and Relevance: The findings of this cohort study indicate that mail-order pharmacy dispensing of mifepristone for medication abortion was effective, acceptable to patients, and feasible, with a low prevalence of serious adverse events. This care model should be expanded to improve access to medication abortion services.

Evaluation of a "smart" screening tool for asynchronous assessment of medication abortion eligibility: A pilot study.

OBJECTIVES: This study aimed to assess the feasibility, safety, and acceptability of asynchronous screening for medication abortion eligibility using a programmed questionnaire. STUDY DESIGN: For this study, we developed an informational website about medication abortion with a linked questionnaire programmed to produce a conclusion regarding eligibility according to standard criteria. We enrolled people in Colorado and Minnesota who submitted questionnaires indicating eligibility. A study physician reviewed each questionnaire and medical records if available and determined whether the responses warranted treatment without a synchronous clinical consultation or ultrasound. If so, the physician prescribed a standard regimen of mifepristone and misoprostol. We collected posttreatment data on abortion outcome, adverse events, and satisfaction. RESULTS: We received questionnaires from 197 individuals, of whom 160 remained in the study until the physician made a final treatment decision. Physicians prescribed medication abortion to 156 (97.5%) individuals based on the questionnaire responses, whereas four needed further assessment to confirm eligibility. Of the 156 individuals, 130 had sufficient follow-up to assess abortion outcome, and 123 (95%) had complete medication abortions without additional treatment. One participant was hospitalized for bleeding, and one expelled a 15-week fetus; however, it is not clear that conventional synchronous history-based screening would have averted these events. Of the 197 questionnaires, 42% were submitted outside business hours. On satisfaction questionnaires, 134 (96%) of 144 participants said they would recommend the study to a friend who needed an abortion. CONCLUSIONS: Data from this pilot project suggest that providing medication abortion based only on a self-administered, programmed questionnaire is likely to be effective, safe, efficient, and acceptable. IMPLICATIONS: A programmed self-administered patient questionnaire to assess eligibility for medication abortion could reduce the cost of the service, augment clinic efficiency, improve quality of care, and enhance access to abortion.

Association of Texas' 2021 Ban on Abortion in Early Pregnancy With the Number of Facility-Based Abortions in Texas and Surrounding States.

Importance: Texas' 2021 ban on abortion in early pregnancy may demonstrate how patterns of abortion might change following the US Supreme Court's June 2022 decision overturning Roe v Wade. Objective: To assess changes in the number of abortions and changes in the percentage of out-of-state abortions among Texas residents performed at 12 or more weeks of gestation in the first 6 months following implementation of Texas Senate Bill 8 (SB 8), which prohibited abortions after detection of embryonic cardiac activity. Design, Setting, and Participants: Retrospective study of a sample of 50 Texas and out-of-state abortion facilities using an interrupted time series analysis to assess changes in the number of abortions, and Poisson regression to assess changes in abortions at 12 or more weeks of gestation. Data included 68 820 Texas facility-based abortions and 11 287 out-of-state abortions among Texas residents during the study period from September 1, 2020, to February 28, 2022. Exposures: Abortion care obtained after (September 2021-February 2022) vs before (September 2020-August 2021) implementation of SB 8. Main Outcomes and Measures: Primary outcomes were changes in the number of facility-based abortions for Texas residents, in Texas and out of state, in the month after implementation of SB 8 compared with the month before. The secondary outcome was the change in the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation during the 6-month period after the law's implementation. Results: Between September 2020 and August 2021, there were 55 018 abortions in Texas and 2547 out-of-state abortions among Texas residents. During the 6 months after SB 8, there were 13 802 abortions in Texas and 8740 out-of-state abortions among Texas residents. Compared with the month before implementation of SB 8, the number of Texas facility-based abortions significantly decreased from 5451 to 2169 (difference, -3282 [95% CI, -3171 to -3396]; incidence rate ratio [IRR], 0.43 [95% CI, 0.36-0.51]) in the month after SB 8 was implemented. The number of out-of-state abortions among Texas residents significantly increased from 222 to 1332 (difference, 1110 [95% CI, 1047-1177]; IRR, 5.38 [95% CI, 4.19-6.91]). Overall, the total documented number of Texas facility-based and out-of-state abortions among Texas residents significantly decreased from 5673 to 3501 (absolute change, -2172 [95% CI, -2083 to -2265]; IRR, 0.67 [95% CI, 0.56-0.79]) in the first month after SB 8 was implemented compared with the previous month. Out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation increased from 17.1% (221/1291) to 31.0% (399/1289) (difference, 178 [95% CI, 153-206]) during the period between September 2021 and February 2022 (P < .001 for trend). Conclusions and Relevance: Among a sample of abortion facilities, the 2021 Texas law banning abortion in early pregnancy (SB 8) was significantly associated with a decrease in the documented total of facility-based abortions in Texas and obtained by Texas residents in surrounding states in the first month after implementation compared with the previous month. Over the 6 months following SB 8 implementation, the percentage of out-of-state abortions among Texas residents obtained at 12 or more weeks of gestation significantly increased.

Clinical and service delivery implications of omitting ultrasound before medication abortion provided via direct-to-patient telemedicine and mail in the U.S.

OBJECTIVES: To compare outcomes among patients who did or did not have pre-abortion ultrasound or pelvic exam before obtaining medication abortion (MA) via direct-to-patient telemedicine and mail. STUDY DESIGN: We analyzed data from participants screened for enrollment into the TelAbortion study at five sites from March 25 to September 15, 2020. We compared participants who had preabortion ultrasound or pelvic exam ("test-MA") to those who did not ("no-test MA"). Outcomes were: abortion not complete with pills alone (i.e., had procedure intervention or ongoing pregnancy), ongoing pregnancy separately, ectopic pregnancy, hospitalization and/or blood transfusion, and unplanned clinical encounters. We used propensity score weighting and multivariable logistic regression to adjust for baseline characteristics. RESULTS: Our analysis included 287 participants who had no-test MA and 125 who had test-MA. Abortion was not complete with pills alone in 16of 287 (5.6%) no-test MA patients compared to 2of 123 (1.9%) test-MA patients (adjusted risk difference [aRD] = 4.3%, 95% confidence interval [CI]: 1.4%-7.1%). No ectopic pregnancies were detected. Groups did not differ regarding hospitalization and/or blood transfusion (p = 0.76) or ongoing pregnancy diagnosis (p = 0.59). Unplanned clinical encounters were more common in no-test MA patients (35of 287, 12.5%) than test-MA patients (10of 125, 8.0%, aRD = 6.7%, 95% CI: 0.5%-13.1%). CONCLUSIONS: Compared to patients who had pre-abortion ultrasound, patients who had no-test MA via telemedicine were more likely to have abortions that were not complete with pills alone and/or unplanned clinical encounters. However, both no-test and test-MA patients had similar and very low rates of ongoing pregnancy and hospitalization or blood transfusion. IMPLICATIONS: Omitting pre-abortion ultrasound before provision of medication abortion via telemedicine does not appear to compromise safety or result in more ongoing pregnancies. However, compared to patients who have preabortion ultrasound, patients who do not have pre-abortion tests may be more likely to seek post-treatment care and have procedural interventions.

Expansion of a direct-to-patient telemedicine abortion service in the United States and experience during the COVID-19 pandemic.

OBJECTIVE: To present updated evidence on the safety, efficacy and acceptability of a direct-to-patient telemedicine abortion service and describe how the service functioned during the COVID-19 pandemic. STUDY DESIGN: We offered the study at 10 sites that provided the service in 13 states and Washington DC. Interested individuals obtained any needed preabortion tests locally and had a videoconference with a study clinician. Sites sent study packages containing mifepristone and misoprostol by mail and had remote follow-up consultations within one month by telephone (or by online survey, if the participant could not be reached) to evaluate abortion completeness. The analysis was descriptive. RESULTS: We mailed 1390 packages between May 2016 and September 2020. Of the 83% (1157/1390) of abortions for which we obtained outcome information, 95% (1103/1157) were completed without a procedure. Participants made 70 unplanned visits to emergency rooms or urgent care centers for reasons related to the abortion (6%), and 10 serious adverse events occurred, including 5 transfusions (0.4%). Enrollment increased substantially with the onset of COVID-19. Although a screening ultrasound was required, sites determined in 52% (346/669) of abortions that occurred during COVID that those participants should not get the test to protect their health. Use of urine pregnancy test to confirm abortion completion increased from 67% (144/214) in the 6 months prior to COVID to 90% (602/669) in the 6 months during COVID. Nearly all satisfaction questionnaires (99%, 1013/1022) recorded that participants were satisfied with the service. CONCLUSIONS: This direct-to-patient telemedicine service was safe, effective, and acceptable, and supports the claim that there is no medical reason for mifepristone to be dispensed in clinics as required by the Food and Drug Administration. In some cases, participants did not need to visit any facilities to obtain the service, which was critical to protecting patient safety during the COVID-19 pandemic. IMPLICATIONS: Medical abortion using telemedicine and mail is effective and can be safely provided without a pretreatment ultrasound. This method of service delivery has the potential to greatly improve access to abortion care in the United States.

"False positive" urine pregnancy test results after successful medication abortion.

OBJECTIVE: To examine the proportion of high-sensitivity urine pregnancy test (HSPT) results that were positive by time after successful medication abortion. STUDY DESIGN: We used data from an ongoing study that provides mifepristone and misoprostol for medication abortion by direct-to-patient telemedicine and mail. Providers evaluated abortion outcomes by patient interview and clinical tests per clinical judgment and participant preference. We identified all participants enrolled July 2016 to September, 2020 who had an HSPT result and no indication of viable pregnancy after treatment. We used logistic regression to examine the association between the timing of the initial post-treatment HSPT, gestational age, and the proportion of HSPTs that gave a positive result. RESULTS: Of the 472 participants in our analysis, 88 (19%) had positive initial HSPTs. The proportions that were positive at ≤20 days, 21 to 27 days, 28 to 34 days, and ≥35 days after mifepristone ingestion was 14 of 29 (48%), 15 of 58 (26%), 49 of 258 (19%), and 10 of 127 (8%), respectively (p < 0.001). Gestational age at mifepristone ingestion was not significantly related to positive HSPT results (p = 0.28). Multivariable logistic regression confirmed both findings and did not identify a statistically significant interaction between these variables. In the 67 participants who relied solely on further HSPTs to confirm abortion outcome, the median interval between the initial positive test and first negative test was 14 days. CONCLUSIONS: The proportion of participants with positive HSPTs declined with time after successful medication abortion. However, nearly one-fifth of participants with complete abortion had positive tests 4 weeks after treatment. IMPLICATIONS: HSPTs provide an inexpensive, convenient option for confirming success of medication abortion at home. However, a substantial minority of patients without ongoing pregnancy have positive HSPT results. Development of a symptom-based strategy for medication abortion outcome assessment without any confirmatory tests should be a priority.

The Association between Immediate Postpartum Etonogestrel Implants and Positive Postpartum Depression Screens in Adolescents and Young Adults.

OBJECTIVE: We aimed to compare rates of positive postpartum depression screens at 6 weeks postpartum among adolescents and young adults (AYA) initiating immediate postpartum contraceptive implants and those initiating other methods. DESIGN: Through a retrospective observational design, we collected data on demographics, reproductive history, prenatal and postnatal depression, and postpartum contraception. SETTING: Patients participating in an AYA prenatal-postnatal program were eligible for inclusion. PARTICIPANTS: A total of 497 patients were enrolled between January 2013 and December 2016. The median age was 19 years (range 13-22 years); 86% were primiparous, 50% were Latina, 24% were black, and 16% were white; 34% initiated immediate postpartum implants (n = 169). INTERVENTION: Those initiating a contraceptive implant within the first 14 days postpartum were included in the intervention group. MAIN OUTCOME MEASURE: We compared rates of positive Edinburgh Postpartum Depression Scales (EDPS) (scores ≥10) in AYA initiating immediate postpartum implants and those initiating other contraceptive methods. RESULTS: The AYA initiating immediate postpartum implants were similar to the rest of the cohort in baseline characteristics, aside from an increased rate of preterm births among the intervention group (19.4% vs 12.1%; P = .03). Prenatally, 14% had an elevated Center for Epidemiologic Studies Depression Scale (CES-D) scores (11.5% immediate postpartum implants vs 15.4% comparison, P = .25). At 6 weeks postpartum, 7.6% had a positive postpartum depression screen; this rate was significantly lower for those initiating immediate postpartum implants compared to those choosing other methods (4.1% vs 9.5%, P = .04). CONCLUSIONS: Providers should continue to encourage AYA to choose whichever highly effective contraceptive method they prefer for postpartum use.

Simulation training for family planning procedures.

PURPOSE OF REVIEW: To review the current evidence for use of simulation in family planning procedural training. RECENT FINDINGS: A variety of simulation models exist for abortion, contraception, and sterilization procedures, ranging from low to high fidelity. Most models for abortion and contraception are low fidelity, inexpensive, and provide opportunities for acquisition and practice of procedural skills. Hysteroscopic and laparoscopic simulation models for sterilization procedures are generally higher fidelity, and their use has been shown to increase knowledge, skill performance, and procedural comfort. SUMMARY: Existing evaluation of family planning simulation education shows consistently positive results related to improved procedural knowledge and comfort. Although some studies have shown increased provision of family planning services following simulation-training interventions, further evaluation is needed to determine the impact on clinical outcomes.

Postplacental intrauterine device expulsion by 12 weeks: a prospective cohort study.

BACKGROUND: An intrauterine device placed immediately following a delivery can serve as an effective and safe contraceptive strategy in the postpartum period. There is limited evidence that the levonorgestrel intrauterine system may have a higher rate of expulsion compared to the copper intrauterine device; however, rates of expulsion for these 2 intrauterine device types have not been compared directly. OBJECTIVE: We sought to compare expulsion rates by 12 weeks' postpartum for the levonorgestrel intrauterine system and copper intrauterine device. STUDY DESIGN: We enrolled women who received postplacental intrauterine devices at 2 urban hospitals. Eligible women were ≥18 years old, English- or Spanish-speaking, with singleton vaginal delivery at ≥35 weeks' gestation. Intrauterine devices were inserted within 10 minutes of placental delivery by trained providers using ring forceps or the operator's hand. Intrauterine device location was evaluated via abdominal ultrasound at 24-48 hours' postpartum, and via transvaginal ultrasound 6 and 12 weeks later, categorizing position of the intrauterine device at the fundus, below the fundus but above the internal os, any part of the intrauterine device below the internal os (partial expulsion), or no intrauterine device visualized. Outcomes included intrauterine device expulsion and method continuation. We used multivariable logistic regression to identify factors associated with expulsion. RESULTS: We enrolled 123 women ages 18-40 years. Of these, 68 (55%) initiated levonorgestrel intrauterine system and 55 (45%) initiated copper intrauterine device. Groups were similar except more copper intrauterine device users were Hispanic (66% vs 38%) and fewer were primiparous (16% vs 31%). Among the 96 (78%) with 12-week follow-up, expulsion was higher for levonorgestrel intrauterine system users (21/55 or 38%) than for copper intrauterine device users (8/41 or 20%) (odds ratio, 2.55; 95% confidence interval, 0.99-6.55; P = .05). At 24 hours' postpartum, there was no significant difference in median distance from the intrauterine device to the fundus between intrauterine device types or between those who did or did not experience expulsion. Of expulsions, 86% occurred ≤6 weeks' postpartum. All complete expulsions were clinically identified, but of the partial expulsions, only 4/10 (40%) were clinically suspected prior to ultrasound. The only independent predictor of expulsion was intrauterine device type. Including reinsertions, intrauterine device use at 12 weeks was not significantly different for levonorgestrel intrauterine system and copper intrauterine device users (80% vs 93%; P = .14). CONCLUSION: Women initiating postplacental levonorgestrel intrauterine system are more likely to experience complete expulsion than those initiating copper intrauterine device. Using sonographic criteria results in higher expulsion rates than previously reported. It is unclear if such high expulsion rates would be identified following standard clinical practice.

Transverse vaginal septum identified in a patient requesting second trimester abortion: a case report.

A primigravid immigrant woman presented for termination of a 16-week pregnancy. The cervix was obscured by a transverse vaginal septum and was only identifiable by ultrasound. We used mifepristone for cervical preparation before concurrent septoplasty and dilation and evacuation.

A case series of removal of nickel-titanium sterilization microinserts from the uterine cornua using laparoscopic electrocautery for salpingectomy.

Nickel-Titanium sterilization microinserts are surgically removed for various indications, including persistent pain. Previously described removal techniques include salpingostomy and cornuectomy with judicious use of electrocautery to avoid potential injury to adjacent structures or fracturing the micoinsert. This case series presents our technique of laparoscopic salpingectomy, utilizing electrocautery on the microinsert.

Outcomes of Elective Outpatient Hysteroscopic Sterilization in Undocumented Women: A Retrospective Analysis.

OBJECTIVE: To determine the feasibility of hysteroscopic sterilization in low-income and unauthorized immigrant women when financial barriers to care are removed. METHODS: Outpatient hysteroscopic sterilization for low-income women at an urban clinic was made possible by grant funding. All procedures were performed by obstetrician/gynecologist attending physicians or supervised trainees. Electronic records were reviewed for cases performed from June 2010 to December 11, 2013. Outcome incidences and complications were determined. Subgroup analyses using demographic and clinical factors were performed. RESULTS: Hysteroscopic sterilization was attempted in 197 patients. Most were Hispanic (93%) and undocumented immigrants (83%). Bilateral placement was achieved on first attempt in 92% (181/197). Successful placement was ultimately achieved in 96% (190/197), and 88% (168/190) returned for hysterosalpingogram (HSG). Appropriate tubal occlusion was documented on 96% (161/168) of HSGs with mean time of 3.5 ± 1.3 months. Repeat HSG at 6 months showed 100% occlusion (7/7). Of the initial cohort, 85% (168/197) could ultimately rely on Essure for contraception. One pregnancy was self-reported 9 months after the procedure; the patient had not followed up for HSG. There were no pregnancies among those who completed follow-up. There were no cases of procedural complications. Successful Essure placement was not associated with age, parity, immigration status, or clinical characteristics (analgesics administered, history of cesarean section, vaginal delivery, cervical surgery, ectopic, fibroids, or pelvic inflammatory disease). The only factor positively associated with HSG follow-up was age 35 years or younger (53% vs. 47%; p = .03). CONCLUSIONS: Successful hysteroscopic sterilization can be achieved in an undocumented, low-income population. Rates of confirmatory HSG follow-up were found to be higher than in the general population. Public funding of programs could decrease unintended pregnancies and pregnancy-related costs.

Comfort With Skills and Knowledge After Immediate Postpartum Intrauterine Device Training.

OBJECTIVE: To estimate whether a standardized immediate postpartum intrauterine device (IUD) simulation results in sustained improvement in perceived comfort with procedural skills. METHODS: From November 2013 to April 2015, obstetric health care providers at two teaching hospitals participated in a 30-minute immediate postpartum IUD simulation workshop and program evaluation. We assessed knowledge of indications, insertion technique, safety, and comfort with knowledge and skills preintervention immediately after and 6 months posttraining. RESULTS: Training participants (N=84) included 39 residents and 45 attendings (25 certified nurse-midwives and 20 obstetrician-gynecologists). Fifty-seven participants (68%) completed the 6-month assessments. Many participants had placed immediate postpartum IUDs before the training (54% of residents compared with 64% of attendings, P=.32); 60% were comfortable with their knowledge and 52% with their insertion skills defined by self-assessment of 7 or greater on a 10-point scale. On the pretest, 77% answered 80% or greater of the knowledge-based questions correctly; this proportion rose to 95% and 97% on the immediate and 6-month assessments, respectively, and were similar between residents and attendings. Immediately posttraining, 94% of participants rated their comfort with knowledge at 7 or greater out of 10; this fell to 86% by 6 months. Likewise, 87% and 74% scored their comfort with skills at 7 or greater out of 10 immediately and at 6 months, respectively. By 6 months, 81% reported placing one or more immediate postpartum IUDs(92% of residents and 71% of attendings, P=.05). CONCLUSION: Residents and attendings demonstrate sustained improvement in knowledge and comfort with immediate postpartum IUDs 6 months after a standardized simulation workshop.

Risk of hemorrhage during surgical evacuation for second-trimester intrauterine fetal demise.

OBJECTIVE: To assess risk of hemorrhage during surgical evacuation for intrauterine fetal demise (IUFD). METHODS: We compared hemorrhage associated with surgical evacuation for IUFDs ≥14weeks to surgical evacuations for other indications. RESULTS: From 12/2005 to 4/2013, 477 in-hospital surgical evacuations met inclusion criteria (123 IUFD, 354 comparators). The groups were demographically similar. Hemorrhage occurred in 7.3% of IUFDs and 4.2% of controls (p=.18). Fetal demise ≥4weeks was associated with hemorrhage (odds ratio 6.8, 95% confidence interval 2.25-20.2). IUFD cases ≥21weeks' gestational age (GA) had greater risk than did similarly aged controls (31.3% vs. 1.8%; p<.001). Abnormal coagulation studies were not associated with hemorrhage. CONCLUSIONS: Hemorrhage was more common in IUFD cases ≥4weeks' duration or ≥21weeks' GA.

Considerations for management of interstitial ectopic pregnancies: two case reports.

BACKGROUND: Conventional treatment of interstitial pregnancies includes systemic methotrexate, direct methotrexate injection, wedge resection, or hysterectomy. We present two cases of interstitial pregnancies that were successfully managed by different minimally invasive surgical techniques. We also report the novel use of hysteroscopic urologic stone retrieval forceps in the transvaginal removal of persistent products of conception after systemic methotrexate for an interstitial pregnancy. CASE PRESENTATION: Case 1 was a 28-year-old gravida 1 white woman at 8 weeks gestation; she was diagnosed with a left interstitial pregnancy. After laparoscopic confirmation of the interstitial pregnancy, successful ultrasound-guided suction dilation and curettage was performed. Case 2 was a 33-year-old gravida 3 para 1021 (one term pregnancy, no preterm pregnancies, one ectopic pregnancy and one spontaneous miscarriage, and one living child) Hispanic woman with persistent products of conception after systemic methotrexate for a left interstitial pregnancy. She underwent hysteroscopic-guided removal of the persistent products of conception, which was possible due to novel use of urologic stone retrieval forceps. CONCLUSIONS: Successful minimally invasive treatment of interstitial pregnancies may be possible in certain cases. Collaboration between different specialties continues to be important for improving minimally invasive options.

Twelve-month contraceptive continuation and repeat pregnancy among young mothers choosing postdelivery contraceptive implants or postplacental intrauterine devices.

OBJECTIVE: To compare discontinuation rates and incidence of repeat pregnancy within 1 year among young mothers choosing postplacental intrauterine devices (IUDs) versus postpartum contraceptive implants. STUDY DESIGN: We enrolled a prospective cohort of postpartum adolescents and young women who chose either postplacental IUDs or postpartum contraceptive implants prior to hospital discharge. We used chart review and phone interviews to assess device discontinuation (by request or expulsion) and pregnancy within 12 months. RESULTS: Of the 244 13-22 year-old participants, 82 chose IUDs (74 levonorgestrel IUDs and 8 copper IUDs), and 162 chose implants. Both groups had participant-requested discontinuation rates of 14% (9/67 IUD; 19/135 implant) within 1 year. Participants choosing IUDs had a 25% (17/67) expulsion rate. Median time to expulsion was 4.1 weeks (range: 0.4-29.3 weeks, 16/17 within 12 weeks), and participants recognized 15/17 expulsions. IUD initiators had significantly higher pregnancy rates by 12 months (7.6% vs. 1.5%, p=0.04). Most pregnancies occurred when women discontinued their initial device and did not start alternative contraception. DISCUSSION: Participant-requested discontinuation was similar in both groups. Differences in overall device discontinuation rates were due to IUD expulsions. Pregnancy rates by 12 months postpartum were lower than previously reported in this age group in both implant initiators and IUD initiators. IMPLICATIONS: Young mothers who choose postplacental IUDs or postpartum contraceptive implants are unlikely to request removal within the first year. Clinicians should counsel postplacental IUD users that early expulsion is common (25%) and may be unrecognized (11% of expulsions). Patients should have a plan for contraceptive management should expulsion occur.

Effect of novel patient interaction on students' performance of pregnancy options counseling.

BACKGROUND: Although options counseling is a fundamental skill for medical providers, previous research has identified gaps in medical school reproductive health education. PURPOSE: To determine if a 1-h novel patient interaction (NPI) improves student performance when caring for a standardized patient with an unintended pregnancy. METHODS: From September 2012 to June 2013 we randomized third-year medical students at the University of Colorado School of Medicine to the standard curriculum plus an NPI, or the standard curriculum only. The NPI consisted of a 1-h small-group session with a patient who discussed her experiences with options counseling and her decision to terminate her pregnancy. Students completed an Objective Structured Clinical Examination (OSCE) at the rotation's end, which included options counseling. The primary outcome was the proportion of participants achieving 'excellence' on the OSCE checklist. 'Excellence' was defined as a score ≥90%. Examinations were flagged as 'unsatisfactory encounters' if core competencies were not addressed. OSCE standardized patients and evaluators were blinded to group assignment. RESULTS: In total, 135 students were eligible and randomized: 75 to NPI; 60 to control. During the OSCE, few students achieved 'excellence' (24% NPI vs. 28% control, p=0.57).There were no differences between scores for components of options counseling. More students in the control group 'appeared somewhat uncomfortable' delivering the pregnancy test results (5% NPI vs. 18% control, p=0.006). More than half (54%) of the intervention group and 67% of controls had 'unsatisfactory encounters' (p=0.16), almost exclusively due to omission of adoption. Most students addressed abortion (96% NPI vs. 92% control, p=0.29). CONCLUSIONS: A 1-h NPI does not improve medical students' performance of pregnancy options counseling and the option of adoption is routinely omitted. Adoption is clearly an area that needs greater attention when designing comprehensive reproductive health curriculum for medical students.

Student perceptions of reproductive health education in US medical schools: a qualitative analysis of students taking family planning electives.

BACKGROUND: Abortion services will be sought by an estimated one in three US women before they reach age 45. Despite the importance of family planning (FP) care, many medical schools do not currently offer formal education in this area, and students are unable to meet associated competency standards prior to graduation. PURPOSE: The purpose of this study was to explore students' motivations in pursuing FP electives throughout the United States, their experiences during these courses, and any impact of these rotations on their plans for future practice. METHOD: We conducted a qualitative study consisting of semi-structured interviews with medical students upon completing fourth-year FP electives at US medical schools. Thirty-seven LCME-accredited US medical schools offered fourth-year FP electives. Course directors at 21 of these institutions recruited study participants between June 2012 and June 2013. Interviews were transcribed, coded, and analyzed with ATLAS/ti software to identify salient themes. RESULTS: We interviewed 29 students representing 14 institutions from all regions of the United States (East Coast, Midwest, South, and West Coast). Five central themes emerged. Medical students are using FP electives to fill gaps in the standard curriculum. Elective participation did not change students' pre-elective stance on abortion. Many students intend to provide abortion in the future but identified possible limiting factors. Proficiency in contraception and options counseling were top competencies desired and gained. Students reported excellent satisfaction with FP electives and would recommend it to their peers, regardless of their personal beliefs. CONCLUSIONS: Interview data revealed that students are using FP electives to fill gaps within preclinical and clinical medical school curriculum. Future physicians will be unable to provide comprehensive care for their female patients if they are not provided with this education. Research should be directed at development and analysis of comprehensive FP curricula, which will allow students to obtain the knowledge necessary to best care for their patients.

Hysteroscopic sterilization in immunocompromised patients who have intrauterine devices in place: two case reports.

INTRODUCTION: The micro-inserts used in the hysteroscopic sterilization procedure elicit a benign occlusive tissue response leading to permanent tubal occlusion. Little is known about whether immunosuppressed patients mount the immunological response necessary to ensure tubal occlusion. Theoretical concern for non-occlusion has limited the use of hysteroscopic sterilization in patients on immunosuppressive therapies. In all patient populations, if an intrauterine device is in place, it is usually removed at the time of hysteroscopic sterilization. Little is known about maintaining intrauterine devices during the 3-month period to tubal occlusion. CASE PRESENTATION: Our patient in case 1 was a 35-year-old Hispanic woman, gravida 2, para 2002, with a history of a living donor kidney transplant. Our patient in case 2 was a 32-year-old Hispanic woman, gravida 3, para 2103, diagnosed with undifferentiated autoimmune disease. Both patients underwent hysteroscopic sterilization. In both cases, a levonorgestrel intrauterine device was in place for contraception. At the time of micro-insert placement, our patients were both on daily immunosuppressive medications, including long-term glucocorticoids. Three months after the hysteroscopic procedure, both patients had successful tubal occlusion, demonstrated by a hysterosalpingogram. CONCLUSION: Hysteroscopic sterilization in an outpatient setting is a reasonable option for sterilization in immunocompromised patients on immunosuppressive therapies. Intrauterine devices can be maintained during the procedure and during the 3-month period to tubal occlusion.