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.

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 single-blinded randomized controlled trial evaluating pain and opioid use after dilator placement for second-trimester abortion.

OBJECTIVES: To compare pain levels and medication needs after placement of laminaria vs Dilapan-S, and after dilation and evacuation (D&E). STUDY DESIGN: We conducted a single-blinded randomized control trial of patients undergoing D&E at 15 0/7 to 23 6/7 weeks gestation, randomizing to cervical preparation with laminaria or Dilapan-S. We compared pain levels and medication usage following dilator placement (5 minutes; 2, 4, and 8 hours; the following morning) and D&E (1, 4, 24, and 48 hours). Our primary outcome was median change from baseline pain, and secondary outcomes included maximum pain timing and overall narcotic use. We compared baseline characteristics, median pain increases and quantities of narcotics used. RESULTS: We analyzed 67 participants with laminaria (n = 34) and Dilapan-S (n = 33). More Dilapan-S users had a prior vaginal delivery (n = 20, 60.6%) than laminaria users (n = 11, 32.4%), p = 0.02. Maximum median pain was not statistically different (Laminaria: +3.5 (interquartile range [IQR] +0.5, +6.5); Dilapan-S: +3 (IQR +1, +5); p = 0.42. Thirty-seven (63.8%) participants reported higher levels of pain following dilator placement than D&E. Overall, 26 (42.6%) participants used narcotics during their abortion episode, with no difference in median number of tablets between laminaria (2, range 1-8) and Dilapan-S (4.5, range 1-15) participants (p = 0.34). CONCLUSIONS: Median pain increase did not differ in participants receiving laminaria or Dilapan-S for cervical preparation prior to D&E. The majority of patients will use a small amount of narcotics if available. IMPLICATIONS: The lack of difference in pain between laminaria and Dilapan-S enhances the applicability of pain intervention research across dilator types. With over half of participants using a small amount of narcotics during their D&E episode, pain management should be individualized to patient needs.

Mesenteric vascular thrombosis associated with disseminated abdominal visceral hemangiosarcoma in a cat.

An adult castrated male cat was evaluated because of a 4 day history of lethargy and partial anorexia. Physical examination revealed abdominal pain with a palpable fluid wave. Cytologic and biochemical analyses of peritoneal effusion were suggestive of septic peritonitis. On surgical exploration of the abdomen, the mesenteric vessels had no palpable pulses and they contained gross thromboses. The intestines were white with no visible peristalsis. Necropsy findings included disseminated, poorly differentiated hemangiosarcoma throughout the abdomen. Mesenteric arterioles contained fibrin thrombi. To the author's knowledge, no previous reports exist of complete mesenteric vascular thrombosis associated with disseminated abdominal visceral hemangiosarcoma in a cat.

Outcome following splenectomy in cats.

No studies have yet examined whether there are prognostic factors for survival for cats undergoing splenectomies. The medical records of 19 cats that had complete splenectomy were reviewed for information on preoperative, intraoperative, and postoperative factors. The most common presenting signs were a palpable abdominal mass in 58% and anorexia in 47% of the cats. Mast cell tumors were the most common reason for splenectomy and were found in 10/19 cats (53%); followed by hemangiosarcoma in 4/19 (21%); and lymphoma in 2/19 (11%). The Kaplan-Meier median survival time (MST) was 197 days, with a range from 2 days to 1959 days. Three cats were noted to have preoperative weight loss, and this was the only factor that had prognostic significance for survival following surgery. For cats with weight loss the MST was 3 days, for cats with no weight loss noted the MST was 293 days (P=0.008).

Intracranial trauma in a dog due to being "swung" at birth.

A male Labrador Retriever neonate presented for evaluation 8 hours after birth because of the onset of generalized seizure activity. The neonate was one of 8 puppies delivered over a 19-hour period to a 4-year-old female Labrador Retriever at an assistance dog breeding colony. Uterine and fetal heart monitoring were performed during the first and second stages of labor; secondary uterine inertia was diagnosed 10 hours after the onset of stage-1 labor. In addition to standard medical therapy, manual assistance was provided for the delivery of all but the second puppy (feathering, pulling, elevating forequarters, abdominal compression). The puppy presented was the third puppy born. At birth, resuscitation efforts were instituted because of a lack of spontaneous breathing and bradycardia. In an effort to remove amniotic fluid from the airways, the puppy was "swung" by an experienced attendee in an arch from mid-abdomen height to knee height while cradled in both hands with the head stabilized. Initial evaluation of the puppy revealed normal blood glucose and no ultrasonographic evidence of hydrocephalus. Because of continued seizure activity, euthanasia and necropsy were elected. At necropsy, there was gross evidence of subdural hematoma formation. Subsequent histopathology of the brain, liver, lung, spleen, small intestine, colon, and kidney revealed subdural and intracerebral hemorrhage. Findings were consistent with high-velocity deceleration trauma ("shaken baby syndrome"). Traditional neonatal resuscitation via "swinging" is a dangerous and potentially lethal practice capable of inducing significant brain trauma in the canine neonate.