Localization and removal of nonpalpable contraceptive implants: Experience from a teaching hospital in Ethiopia: A case series.

OBJECTIVE: To assess the outcome of women presenting with nonpalpable contraceptive implants to a referral center in Ethiopia. In addition, we discuss our approach and experience with localization and removal of nonpalpable contraceptive implants. METHODS: We conducted a facility-based retrospective review of patients evaluated for a nonpalpable contraceptive implant between September 2019 and March 2022 at St. Paul's Hospital Millennium Medical College (SPHMMC) located in Addis Ababa, Ethiopia. SPHMMC is a tertiary teaching hospital with Obstetrics and Gynecology (OBGYN) residency as well as a Family Planning fellowship program. The present study was approved by the institutional review board of SPHMMC. RESULTS: Of the 68 patients reviewed, 48 were referred from other facilities. A total of 24 (35.3%) patients had at least one previous failed attempt at removal before referral. On ultrasound examination, 27 (40.3%) implants were found below the muscle fascia. Implant removal procedures were successfully done at the outpatient clinic in 65 (95.6%) patients including 40/40 (100%) suprafascial and 25/27 (92.6%) subfascial implants. Removal of subfascial implants was performed in the operating room in two patients. We failed to localize the device in one patient currently on follow-up. All removals were performed by OBGYNs with subspecialty training in family planning or current fellows supervised by subspecialists. No post-procedure complications have been documented. CONCLUSION: Our findings show that with meticulous evaluation and careful patient selection, localization and removal of nonpalpable implants in outpatient settings are successful. Initial ultrasonography minimizes delays and allows for same-day implant localization and removal.

Foley catheter for cervical preparation prior to second trimester dilation and evacuation: A supply-based alternative for surgical abortion: A case series.

Objective: To document the use of Foley catheter as an alternative to osmotic dilators for cervical preparation before second trimester dilation and evacuation at a tertiary setting in Ethiopia. Methods: This is a retrospective case series conducted at St. Paul's Hospital Millennium Medical College (Ethiopia) from April 1, 2021 to August 30, 2021. Forty-three cases of dilation and evacuation (D&E) in which overnight intra-cervical Foley catheter placement was used to prepare the cervix were reviewed. Data were analysed using SPSS version 23 and simple descriptive statistics were applied to analyze the clinical characteristics of study subjects and procedure outcomes. Percentages and frequencies were used to present the findings. Results: The calculated median gestational age was 21.4(17-24.2) weeks. Around 40%(17/43) of cases had cervical dilation of 3 to 4 cm, with another 33% (14/43) achieving cervical dilation of 1.5 to 2.5 cm. Additional dilation during the procedure was required only in 12 cases (28%) prior to D&E procedure. In 36 cases (84%), the procedure was attended by family planning fellow. Conclusion: Cervical preparation using overnight Foley catheter before second-trimester D&E resulted in majority of the cases requiring no additional dilation immediately prior to D&E procedure. Where osmotic dilators are not available, Foley catheter can be an alternative method to prepare the cervix prior to D&E procedures. Implications: In the absence of osmotic dilators, Foley catheter can be used as an alternate, and readily available means of cervical preparation for second trimester D&E procedures.

Effectiveness of intra-cardiac lidocaine and intra-amniotic digoxin at inducing fetal demise before second trimester abortion past 20 weeks at a tertiary Hospital in Ethiopia: A retrospective review.

Background: Current literature recommends inducing fetal demise prior to second trimester medication abortion beyond 20 weeks of gestation. There is inadequate literature regarding the practice and effectiveness of this procedure in low-income countries, such as Ethiopia. This study aimed at documenting the effectiveness of intra-cardiac lidocaine and intra-amniotic digoxin at inducing fetal demise before second trimester medication abortion in an Ethiopian setting. Methods: This is a retrospective chart review conducted at St. Paul's Hospital Millennium Medical College, in Ethiopia. A total of 65 cases of feticide administration before 2nd trimester medication abortion between 20 and 28 weeks of gestation (From April 1, 2021 to September 30, 2021) were reviewed. The primary outcome was cessation of fetal cardiac activity the day after the first feticide injection. Data were extracted by reviewing maternal charts using a data extraction tool prepared in English. Data were analyzed using SPSS version 23. Simple descriptive statistics were used to analyze baseline characteristics and fetal demise outcomes. Results were presented in percentages and frequencies. Results: More than three quarters of the feticide injections were with intra-amniotic digoxin, while the rest (24.6%, 16/65) were with intra-cardiac lidocaine. Injection of digoxin or lidocaine was effective at inducing fetal demise the day after administration in 92.3% (60/65) of the cases. Intracardiac lidocaine administration was 100% (16/16) effective at inducing fetal demise within the day after the injection while the effectiveness of digoxin within the same period was 89.8%. Conclusion: In this study, both intra-amniotic digoxin and intra-cardiac lidocaine were effective at inducing fetal demise, which is in support of findings from similar previous studies. Implications: In an Ethiopian setting, both intra-amniotic digoxin and intra-cardiac lidocaine injections are effective at inducing fetal demise before second trimester abortion beyond 20 weeks of gestation within the next day after feticide administration.

The impact of having a dedicated obstetrics and gynecology resident to provide contraceptive counseling on immediate postpartum family planning uptake: a "pre-post" study.

BACKGROUND: Providing effective, high quality, antenatal and postpartum contraceptive counseling can reduce unintended pregnancies, decrease maternal and fetal morbidity and mortality, and prevent unsafe abortions. The postpartum period is a critical time to address unmet family planning need and to reduce the risks of short interpregnancy interval. This study aimed at determining the impact of assigning a dedicated obstetrics and gynecology resident for postpartum family planning counselling on the uptake of immediate postpartum family planning. METHODS: A "pre-post" observational study was conducted at Saint Paul's Hospital Millennium Medical College (SPHMMC), in Addis Ababa-Ethiopia, from May 1, 2021 to June 30, 2021. Immediate postpartum family planning uptake between the months of June (when there was a dedicated resident assigned for postpartum family planning counselling and provison on weekdays) and May (when there was no such dedicated resident for similar purpose) were compared. Data was analyzed using SPSS version 20 software packages. Simple descriptive was used to describe baseline characteristics. Chi-square test of association was done to determine the correlation between dependent and independent variables. Multivariate regression analysis was applied to determine factors associated with uptake of family planning methods in the immediate postpartum period. Odds ratio, 95% CI, and p-value < 0.05 were used to describe results significance. RESULTS: Out of 776 mothers who delivered at SPHMMC in the month of June 2021, 158 (20.4%) of them used immediate postpartum family planning. This finding during the month of June is higher than a 15.4% immediate postpartum family planning uptake observed during the preceding month of May. Having a dedicated resident for postpartum family planning counselling was associated with an increase in immediate postpartum family planning use (AOR = 1.31, 95% CI [1.01, 1.69]). CONCLUSION: In this study, presence of a dedicated obstetrics and gynecology resident for postpartum family planning counselling was associated with an increase in the uptake of immediate postpartum family planning. This implies the importance of assigning a dedicated care provider for the purpose of postpartum family planning counselling within the immediate postpartum, which gives postpartum women another opportunity of adequate counselling before they are discharge from Hospitals or obstetric service centers.

The postpartum period is a critical time to address unmet family planning need and to reduce the risks of short interpregnancy interval and unintended pregnancies, which translates in to a decrease in maternal and fetal morbidity and mortality. In this study, postpartum women who were counselled for family planning by dedicated obstetrics and gynecology resident were more likely to use immediate postpartum family planning (PPFP) compared to women who were not counselled by such care provider. This study aimed at determining the impact of assigning a dedicated obstetrics and gynecology resident for postpartum family planning counselling, by comparing immediate PPFP (family planning provided after delivery and before discharge of mothers from Hospital) uptake between the months of June (when there was a dedicated resident) and May (when there was no dedicated resident), in 2021. Out of 908 deliveries during the month of May, the uptake of immediate PPFP was 15.4%, which was significantly lower than an uptake of 20.4% in the following month of June. Mothers who delivered during the month of June were 1.3 times more likely to use immediate PPFP than mothers who delivered in the preceding month of May. In conclusion, presence of a dedicated obstetrics and gynecology resident for postpartum family planning counselling was associated with an increase in the uptake of immediate postpartum family planning.

Risk-based screening for Chlamydia trachomatis and Neisseria gonorrhoeae prior to intrauterine device insertion.

OBJECTIVE: The objective was to compare three strategies for Chlamydia trachomatis and Neisseria gonorrhoeae screening prior to intrauterine device (IUD) insertion. STUDY DESIGN: This was a secondary analysis of the Contraceptive CHOICE Project. We measured the prevalence of C. trachomatis and/or N. gonorrhoeae at the time of IUD insertion. We then compared sensitivity, specificity, negative and positive predictive values, and likelihood ratios for three screening strategies for C. trachomatis and N. gonorrhoeae prior to IUD insertion: (a) "age-based" ­ age ≤25 years alone; (b) "age/partner-based" ­ age ≤25 and/or multiple sexual partners; and (c) "risk-based" ­ age ≤25, multiple sexual partners, inconsistent condom use and/or history of prior sexually transmitted infection (STI). RESULTS: Among 5087 IUD users, 140 (2.8%) tested positive for C. trachomatis, 16 (0.3%) tested positive for N. gonorrhoeae, and 6 (0.1%) were positive for both at the time of IUD insertion. The "risk-based" screening strategy had the highest sensitivity (99.3%) compared to "age-based" and "age/partner-based" screening (80.7% and 84.7%, respectively.) Only one (0.7%) woman with a chlamydia or gonorrhea infection would not have been screened using "risk-based" screening. CONCLUSION: A risk-based strategy to screen for C. trachomatis and N. gonorrhoeae prior to IUD insertion has higher sensitivity than screening based on age alone or age and multiple sexual partners. IMPLICATIONS: Using a risk-based screening strategy (age≤25, multiple sexual partners, inconsistent condom use and/or history of an STI) to determine who should be screened for C. trachomatis and N. gonorrhoeae prior to IUD insertion will miss very few cases of infection and obviates the need for universal screening.

Risk of bacterial vaginosis in users of the intrauterine device: a longitudinal study.

BACKGROUND: Users of the intrauterine device (IUD) may be at increased risk for bacterial vaginosis (BV). Our objective was to compare the incidence of BV in women using the IUD with women using combined oral contraceptives (COC), the contraceptive vaginal ring, and the contraceptive patch. METHODS: We prospectively recruited women negative for BV at baseline. Monthly, for 6 months, participants returned a self-obtained vaginal smear for Gram stain by mail. BV was diagnosed by a Nugent score ≥7. We performed Cox proportional hazards regression to investigate associations between demographic and behavioral characteristics, contraceptive method, and incident BV. RESULTS: We enrolled 153 women negative for BV at baseline; 90 (59%) women who chose the IUD and 63 (41%) who chose COC, ring, or patch. There were 35 women with BV at one or more time points. The incidence of BV was 37.0% among IUD users and 19.3% in COC, ring, and patch users (P = 0.03). In the univariate analysis, race, IUD use, intermediate flora, and irregular vaginal bleeding were significantly associated with BV. In the adjusted model, IUD users were no more likely to acquire BV (hazards ratio [HRadj]: 1.28, 95% confidence interval [CI]: 0.53-3.06) than COC, ring, and patch users. The associations between intermediate flora and irregular bleeding and BV remained significant (HRadj: 3.30, 95% CI: 1.51-7.21, and HRadj: 2.54, 95% CI: 1.03-6.24, respectively). CONCLUSIONS: The association between IUD use and BV appears to be mediated by irregular vaginal bleeding. Intermediate flora is associated with an increased incidence of BV.