Medical management of ectopic pregnancy in a family planning clinic: A case series.

OBJECTIVE: To evaluate safety of medical management of ectopic pregnancy in a free-standing family planning clinic setting. STUDY DESIGN: We retrospectively reviewed cases of ectopic pregnancy between January 2014 and December 2018 which were identified using a "Beta Board" tracking system. Planned Parenthood of Orange and San Bernardino Counties staff added patients the "Beta Board" if they had a positive urine pregnancy test without definitive ultrasound diagnosis of intrauterine pregnancy and/or symptoms suggestive of ectopic pregnancy, such as vaginal bleeding, and cramping. Patients were included in the study if they had received a final diagnosis of ectopic pregnancy. RESULTS: Of 5083 patients tracked via the Beta Board, 260 patients presented to a Planned Parenthood free-standing, family planning clinic with ectopic pregnancy. Ninety-five patients were treated with methotrexate entirely at the clinic. There were no deaths. Four ectopic pregnancies ruptured and 8 required surgery. CONCLUSION: Treatment of ectopic pregnancy with methotrexate in the family planning clinic setting can be safe and effective with reassuring outcomes that are similar to the hospital setting.

Serum human chorionic gonadotropin decline following aspiration abortion in early pregnancy less than 42 days gestation.

OBJECTIVE: To define serum human chorionic gonadotropin (hCG) decline following complete aspiration abortion. STUDY DESIGN: We performed a secondary analysis of 86 patients who underwent uncomplicated aspiration abortion for ultrasound-confirmed pregnancy ≤42 days gestation and had serum hCG at the time of aspiration and within 3 days postprocedure. RESULTS: Median hCG declines were 72.9% by day 1 (n = 14), 87.6% by day 2 (n = 50), and 92.8% by day 3 (n = 22). Ninetieth percentile declines were 67.8%, 81.5%, and 90.8%. Minimum hCG declines were 56.2%, 77.3%, and 83.2%. Trends did not vary by gestational age or by initial hCG <3000 mIU/mL. CONCLUSION: Postprocedure hCG trend varies over the first few days in early gestation. At ≤42 days gestation, serial hCG decline at 1 day after completed aspiration abortion is greater than 50%, consistent with the decline observed in medication abortion. IMPLICATIONS: This study confirms previously estimated human chorionic gonadotropin decline after aspiration abortion of at least 50% at 24 hours for completed procedure in very early gestations. Minimum declines on days 2 and 3 are approximately 70% and 80%.

Safety and effectiveness of medication and aspiration abortion before or during the sixth week of pregnancy: A retrospective multicenter study.

OBJECTIVE: To compare adverse outcomes of medication and aspiration abortion among those with intrauterine pregnancy <43 days gestation versus abortions performed at 43-48 days. STUDY DESIGN: We conducted a multicenter retrospective chart review study to review all medication and aspiration abortion of visualized pregnancy <49 days gestation at Planned Parenthood Columbia Willamette (Oregon) and Planned Parenthood of Orange and San Bernardino Counties (California) in 2014-2015. We identified incident cases by billing codes and performed chart review for adverse outcomes (ED visits, incomplete abortion), need for further interventions, or complications (hemorrhage, infection, and uterine perforation), captured up to 90 days post-abortion. RESULTS: The 3930 abortions during the study period at the two sites included 2914 medication abortions and 1016 aspiration abortions, with 1470 medication abortions and 469 aspiration abortions at <43 days gestation. Composite adverse outcomes did not vary by gestation, for either medication abortion (75/1470; 5.1% for <43 days versus 94/1444; 6.5% at 43-48 days, p = 0.10) or aspiration (12/469; 2.6% for <43 days versus 16/547; 2.9% at 43-48 days, p = 0.72). Fewer incomplete abortions (ongoing pregnancy, symptomatic retained tissue, or retained gestational sac) occurred in the earlier gestational group (3.1% for <43 days versus 4.3% at 43-48 days, p = 0.04). Composite adverse outcomes were higher after medication versus aspiration abortion (169/2914; 5.8% versus 28/1016; 2.7%, p < 0.01). CONCLUSION: Medication and aspiration abortion performed either before or during the sixth week of ultrasound-confirmed intrauterine pregnancy have low rates of composite adverse outcomes, including complications or incomplete abortion. However, unplanned interventions are more common after medication compared to aspiration abortions. IMPLICATIONS: Very early medication and aspiration abortion are similarly safe and effective before or during the sixth week of ultrasound-confirmed pregnancy, though subsequent interventions are more likely after medication abortion. Patients with early pregnancy can safely initiate abortion with follow-up to ensure complete abortion.

A qualitative study of digoxin injection before dilation and evacuation.

OBJECTIVE: We sought to qualitatively understand patients' experiences with digoxin as a step before dilation and evacuation (D&E). STUDY DESIGN: We recruited English-speaking women from one abortion health center where digoxin is routinely used before D&E. We interviewed participants one to three weeks after the D&E about physical and emotional experiences with digoxin and understanding of its purpose. Using grounded theory, we analyzed transcripts iteratively, identifying themes from interviews; we stopped recruitment when we reached thematic saturation. RESULTS: We conducted 20 interviews and participants described mixed experiences. Three overarching themes from the qualitative interviews were: (1) physical and emotional discomfort; (2) varied understanding of digoxin's purpose and effects; and (3) reassurance. Most participants described significantly negative experiences with digoxin; however, many participants also described positive aspects of the injection intermingled with those negative experiences. CONCLUSIONS: Participants' experiences with digoxin before D&E were both polarized and nuanced. While participants were largely clear about digoxin's action, they were much less clear about the reason for its use. IMPLICATIONS: Both the clinical purpose for and patients' experiences with digoxin before D&E are complicated. Providers who continue to use digoxin should consider patient preferences in how they offer digoxin, and consider tools to ensure patient understanding.

A Narrative Engagement Framework to Understand HPV Vaccination Among Latina and Vietnamese Women in a Planned Parenthood Setting.

Disparities in cervical cancer and human papillomavirus (HPV) vaccination persist among Vietnamese and Latina women. Through a partnership with Planned Parenthood of Orange and San Bernardino Counties (PPOSBC) in Southern California, we conducted in-depth interviews with young adult Latina ( n = 24) and Vietnamese ( n = 24) women, and PPOSBC staff ( n = 2). We purposively sampled vaccinated women to elicit HPV vaccine decision narratives to uncover rich data on motivators, cultural values, and implicit vaccine attitudes. Unvaccinated women were interviewed to identify barriers. Women were also asked to discuss their observations of men's HPV vaccine attitudes. Narrative engagement theory guided the study privileging the meaning women ascribed to their experiences and conversations related to vaccine decision making. Vaccine decision narratives included (a) mother-daughter narratives, (b) practitioner recommendation of HPV vaccination, (c) independence narratives among Vietnamese women, (d) HPV (un)awareness narratives, and (d) school exposure to HPV knowledge. Barriers to vaccinating included trust in partner HPV status, and family silence and stigma about sexual health. Participants conveyed the importance of including messages aimed at reaching men. Practitioners described insurance barriers to offering same day vaccination at PPOSBC health center visits. Narrative communication theory and methodology address health equity by privileging how Vietnamese and Latina women ascribe meaning to their lived experiences and conversations about HPV vaccination. Identifying authentic and relatable vaccine decision narratives will be necessary to effectively engage Vietnamese and Latina women. These findings will guide the process of adapting an existing National Cancer Institute research-tested HPV vaccine intervention.

Primary care physician familiarity with U.S. medical eligibility for contraceptive use.

BACKGROUND: In May 2010, the Centers for Disease Control and Prevention (CDC) released the US Medical Eligibility Criteria for Contraceptive Use (MEC) to provide evidence-based guidance on contraceptive safety in US women with medical conditions. The CDC MEC was adapted from similar World Health Organization (WHO) guidelines. METHODS: A total of 754 US obstetrician-gynecologists, family physicians, and internists were surveyed at national conferences specific to each specialty between April and September 2011. The survey assessed prior use of the WHO and CDC MEC and provided case questions to answer using the CDC MEC guidelines. RESULTS: The respondents included 190 (25%) obstetrician-gynecologists, 326 (43%) family physicians, and 239 (32%) internists. Only 39% of respondents had heard of either MEC, and only 23% had previously used one or both MECs. Among the 120 (16%) respondents who had previously used the CDC MEC, utilization rates differed significantly by specialty (27%, 12%, and 13%, respectively) but not by gender. When the CDC MEC was provided for participants to use for two case questions, only 39% and 80% of participants gave correct answers. CONCLUSIONS: Although the CDC MEC is designed to be used regularly by primary care and specialty physicians, relatively few used it in the first year after its release. Even when the CDC MEC is provided to assist in answering case questions, physicians appear to have difficulty answering correctly. More work is needed to disseminate and clarify the CDC MEC.

Myths and misconceptions about long-acting reversible contraception (LARC).

PURPOSE: To discuss common myths and misconceptions about long-acting reversible contraception (LARC) among patients and health care providers. METHODS: We address some of these common myths in an effort to provide clinicians with accurate information to discuss options with patients, parents, and referring providers. The list of myths was created through an informal survey of an online listserv of 200 family planning experts and from the experiences of the authors. RESULTS: When presented with information about LARC, adolescents are more likely to request LARC and are satisfied with LARC. Clinicians have an important role in counseling about and providing LARC to their adolescent patients as well as supporting them in managing associated side effects. CONCLUSIONS: This review article can be used as a resource for contraceptive counseling visits and for the continuing education of health professionals providing adolescent reproductive health care.

Transvaginal administration of intraamniotic digoxin prior to dilation and evacuation.

BACKGROUND: Transabdominal injection of digoxin into the amniotic fluid or fetus to induce fetal demise before dilation and evacuation (D&E) abortion has become common practice since the passage of the Partial-Birth Abortion Ban Act in 2007. STUDY DESIGN: We performed a prospective study to assess the feasibility of transvaginal administration of intraamniotic digoxin the day before D&E. All women between 18 0/7 and 23 5/7 weeks of gestation seeking termination from December 2009 to May 2011 were approached for study participation. Women who declined participation were asked to identify their primary rationale. For women declining study participation, transection of the umbilical cord during D&E was performed to meet the requirements of the ban. RESULTS: Over 18 months, 134 women met study entry criteria and 108 (81%) declined to participate. Of the 26 women who enrolled, 1.0 mg undiluted digoxin was successfully administered transvaginally in 24 (92%, 95% confidence interval 75%-99%). The most common reasons for declining participation were discomfort with preoperatively inducing fetal demise (37%) and desire to avoid a medically unnecessary medication (36%). CONCLUSIONS: Transvaginal administration of digoxin is a feasible alternative to transabdominal administration to induce preoperative fetal demise. The majority of women decline digoxin administration when an alternative is available.

Women's information-seeking behavior after receiving contraceptive versus noncontraceptive prescriptions.

BACKGROUND: Contraceptives are among the most commonly prescribed medications used by women of reproductive age, but little is known about women's information-seeking behavior after receiving prescriptions for medication. STUDY DESIGN: All reproductive-age women who visited one of four primary care clinics in Western Pennsylvania between October 2008 and April 2010 were invited to complete a follow-up survey after their visit which included questions regarding medications prescribed, information-seeking after their visit and their perceptions of the quality of the information they found. RESULTS: Of the 218 women prescribed contraceptives, 49% sought additional information after their visit. In models adjusted for sociodemographic and reproductive characteristics of the respondents, women who received a contraceptive prescription were twice as likely to seek additional information about their medication as women who received noncontraceptive prescriptions [odds ratio (OR)=2.06, 95% confidence interval (CI) 1.47-2.90]. Women who received a contraceptive prescription were more likely to seek information from the Internet (OR=1.84, 95% CI 1.26-2.70) and from the package insert (OR=1.55, 95% CI 1.02-2.36) than women who received noncontraceptive prescriptions. CONCLUSIONS: Women frequently sought additional information on contraceptive prescriptions. Efforts are needed to increase the quantity and improve the quality of contraceptive counseling provided by primary care providers and the quality of the information provided by package inserts and the Internet.

Comparison of 3 dilation and evacuation technical skills models.

BACKGROUND: Simulation training may improve patient safety, decrease trainer and trainee anxiety, and reduce the number of cases needed for competency. Complications associated with dilation and evacuation (D&E) have been directly related to provider skill level, yet no low-fidelity model has been formally described or evaluated in the literature for second-trimester D&E training. OBJECTIVE: We report physicians' assessments of the realism of 3 D&E models to establish a composite training model. METHODS: We surveyed experienced providers at 2 national conferences to evaluate 3 D&E models and rate each model's components on a Likert scale. RESULTS: Fifty-five obstetrics-gynecology and family medicine physicians completed the survey. Most respondents rated 4 components of 1 model as somewhat realistic or very realistic. The components rated highest were the fetal parts (82% [45 of 55]) and placenta (60% [30 of 50]). This model was rated as more likely to be used in training by 80% (43 of 54) of participants than the 2 other models, as rated by 28% (15 of 54) and 9% (5 of 54) of participants. CONCLUSIONS: A model made from a plastic bottle containing a stuffed fabric form with detachable parts has tactile similarity to a D&E procedure and should be further developed for testing and training.

Antiabortion violence in the United States.

BACKGROUND: This study was conducted to determine if an association exists between the amount of harassment and violence directed against abortion providers and the restrictiveness of state laws relating to family planning. STUDY DESIGN: We used responses from a July 2010 survey of 357 abortion providers in 50 states to determine their experience of antiabortion harassment and violence. Their responses were grouped and analyzed in relation to a published grading of state laws in the United States (A, B, C, D and F) as they relate to restrictions on family planning services. RESULTS: Group by group comparison of respondents illustrates that the difference in the number of reported incidents of minor vandalism by group is statistically significant (A vs. C, p=.07; A vs. D, p=.017; A vs. F, p=.0002). Incidents of harassment follow a similar pattern. There were no differences noted overall for violence or major vandalism. Major violence, including eight murders, is a new occurrence in the last two decades. CONCLUSIONS: Harassment of abortion providers in the United States has an association with the restrictiveness of state abortion laws. In the last two decades, murder of abortion providers has become an unfortunate part of the violence.