Pregnancy options counseling.

PURPOSE OF REVIEW: This article reviews key aspects of pregnancy options counseling, and highlights how inappropriate counseling can create barriers to timely and safe abortion care. RECENT FINDINGS: Access to safe abortion services in the United States is increasingly constrained. One way to combat this hostile environment is to ensure that individuals presenting for care early in pregnancy have access to comprehensive and unbiased pregnancy options counseling. There are unfortunately many barriers to individuals receiving adequate pregnancy options counseling, and marginalized groups experience disproportionate effects of inappropriate counseling. Research shows that individuals desire appropriate pregnancy options counseling when seeking early pregnancy care, and that providers often serve as a barrier to this care. Provider miseducation and opposition to pregnancy options counseling, particularly as it concerns abortion care, creates challenges and delays for people seeking abortion services. Crisis Pregnancy Centers use misinformation to further these barriers to appropriate care. SUMMARY: Nondirective and patient-centered pregnancy options counseling is standard of care. People seeking pregnancy options counseling desire and deserve comprehensive and accurate information. Providers must not serve as barriers to safe and appropriate care. Increasing nondirective pregnancy options counseling research, education, and training is crucial to ensuring access to safe and appropriate abortion care.

Racial Disparities in Mental Health Outcomes Among Women With Early Pregnancy Loss.

OBJECTIVE: To explore the relationship between race and depression symptoms among participants in an early pregnancy loss clinical trial. METHODS: We performed a planned secondary analysis of a randomized trial by comparing treatments for medical management of early pregnancy loss. We hypothesized that Black participants would have higher odds of risk for major depression (measured with the CES-D [Center for Epidemiological Studies-Depression] scale) 30 days after early pregnancy loss treatment when compared with non-Black participants. We analyzed the data as a cohort, with the primary exposure being race and secondary exposure being high adverse childhood experience scores (measured with the Adverse Childhood Experience scale). Our primary outcome was risk for major depression (score of 21 or higher on the CES-D scale) 30 days after early pregnancy loss treatment. RESULTS: Three hundred participants diagnosed with a nonviable intrauterine pregnancy from 5 to 12 weeks of gestation were randomized as part of the original trial from May 2014 to April 2017. Of 275 respondents included in this analysis, 120 [44%] self-identified as Black and 155 [56%] self-identified as non-Black. After early pregnancy loss treatment, 65 [24%] participants were at risk for major depression. Black participants had an increased risk for major depression (57%) after early pregnancy loss treatment compared with non-Black participants (43%; odds ratio [OR] 2.02; 95% CI 1.15-3.55). After adjustment for risk for baseline depression, adverse childhood experience score, and parity, the odds of risk for major depression 30 days after pregnancy loss treatment remained higher for Black participants when compared with non-Black participants (OR 2.02; 95% CI 1.15-3.55; adjusted OR 2.48; 95% CI 1.28-4.81). CONCLUSION: Overall, approximately one quarter of women who experience an early pregnancy loss are at an increased risk for major depression 30 days after treatment. This risk is about twice as high for Black women compared with non-Black women. There is a need for appropriate mental health resources for women undergoing early pregnancy loss care. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02012491.

Opioid prescription for pain after osmotic dilator placement in abortion care: A randomized controlled trial.

OBJECTIVE: To compare the overnight maximum pain scores after osmotic dilator placement prior to a dilation and evacuation (D&E) procedure in participants assigned to a prescription for ibuprofen alone or to ibuprofen plus oxycodone. STUDY DESIGN: We conducted a nonblinded pragmatic, randomized controlled trial to evaluate pain management among women undergoing osmotic dilator placement prior to D&E. We randomly assigned 70 participants at 12 weeks 6 days to 23 weeks 6 days gestation to receive a prescription for ibuprofen alone, or ibuprofen plus oxycodone. We assessed pain using a numeric rating scale (NRS; scale 0-10) at the following time points: Baseline, dilator placement, 2 and 6 hours, and preoperatively, where we also asked participants their maximum pain score. The primary outcome was mean individual NRS pain score change from baseline to maximum pain score. RESULTS: Maximum mean pain score (change from baseline) was 4.7 ± 2.9 in the ibuprofen group, and 6.5 ± 2.5 in the ibuprofen plus oxycodone group (p < 0.01). Participants in both groups reported highest NRS pain scores 2 hours after dilator placement, 3.9 ± 2.5 and 5.3 ± 2.6 respectively (p = 0.02). Average ibuprofen use in both arms was similar, and 81% of participants used at least 1 dose of ibuprofen after dilator placement. Of those randomized to prescription to ibuprofen plus oxycodone, only 51% used a dose of oxycodone. CONCLUSIONS: Compared to participants randomized to receive a prescription for ibuprofen, those randomized to receive a prescription for ibuprofen plus oxycodone reported higher maximum overnight pain scores. IMPLICATIONS: Participants receiving a prescription for ibuprofen alone had lower maximum overnight pain scores following osmotic dilator placement. Given that opioid prescriptions did not appear to reduce overnight pain, minimizing these prescriptions would avoid opioid exposure for patients undergoing D&E.

Prioritizing Desiredness in Pregnancy of Unknown Location: An Algorithm for Patient-Centered Care.

Patient-centered care is one of the six aims for improvement in health care quality outlined by the National Academy of Medicine (previously known as the Institute of Medicine). We propose an algorithm for patients who are presenting with a pregnancy of unknown location that emphasizes pregnancy desiredness to improve patient-centered care. Health care professionals should assess pregnancy desiredness at a patient's initial consultation for evaluation of pregnancy of unknown location; desiredness, along with other clinical criteria, should guide management. For women with an undesired pregnancy, health care professionals should offer expedient active management. Uterine aspiration will allow for quick clinical diagnosis and resolution of the pregnancy. Alternatively, for women with a desired pregnancy or for those who are ambivalent, we recommend careful conservative management. Adopting this algorithm will recenter the patient in the complex management of pregnancy of unknown location.

Gestational Trophoblastic Neoplasia After Human Chorionic Gonadotropin Normalization Following Molar Pregnancy: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate the incidence of gestational trophoblastic neoplasia following complete and partial molar pregnancy after reaching normal human chorionic gonadotropin (hCG) levels to guide evidence-based follow-up recommendations. DATA SOURCES: MEDLINE, EMBASE, Web of Science, POPLINE, Cochrane, and ClinicalTrials.gov were searched from inception to November 2018, using the intersection of "gestational trophoblastic disease," "molar pregnancy," and "human chorionic gonadotropin" themes. METHODS OF STUDY SELECTION: Search results were screened to identify cohort studies of molar pregnancy reporting gestational trophoblastic neoplasia development, with at least 6 months of intended normal hCG follow-up. TABULATION, INTEGRATION, AND RESULTS: Two reviewers independently identified articles for inclusion. Data were extracted using a standardized form. For meta-analysis, cumulative incidence of gestational trophoblastic neoplasia, with CIs by the Agresti-Coull method, and pooled risk ratios (RRs) comparing complete and partial mole were calculated. Among the 19 eligible studies that reported adequate data for inclusion in the primary meta-analysis, we found low incidence of gestational trophoblastic neoplasia after normal hCG level following both complete mole (64/18,357, 0.35%, 95% CI 0.27-0.45%), and partial mole (5/14,864, 0.03%, 95% CI 0.01-0.08%). There was a significantly higher risk of gestational trophoblastic neoplasia after complete compared with partial molar pregnancy (RR 4.72, 95% CI 1.81-12.3, P=.002). Among gestational trophoblastic neoplasia cases after normal hCG level following complete mole, 89.6% occurred when the time from evacuation to normalization was 56 days or longer, and 60.7% were diagnosed beyond the commonly recommended 6-month surveillance interval. Sensitivity analyses, including those limiting to studies at low risk of bias, did not significantly affect results. We found an overall incidence of gestational trophoblastic neoplasia of 15.7% for complete mole (1,354/8,611, 95% CI 15.0-16.5%) and 3.95% for partial mole (221/5,593, 95% CI 3.47-4.50%). CONCLUSION: Gestational trophoblastic neoplasia development after normal hCG level following molar pregnancy is rare. Recommendations for frequency and duration of hCG follow-up can be minimized to lessen burden on patients and informed by the type of molar pregnancy and time interval from uterine evacuation to hCG normalization. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42019116414.

Management of early pregnancy loss, with a focus on patient centered care.

Early pregnancy loss is the most common complication in pregnancy. Management options for miscarriage include expectant management, medical intervention, or surgical aspiration. Non-surgical and surgical management are all safe and acceptable options for medically uncomplicated patients. Patient and provider preferences contribute profoundly to clinical decisions about miscarriage management. Shared-decision making and evidence based counseling have been shown to significantly improve patient satisfaction with early pregnancy loss care. This review article will discuss the epidemiology and risk factors of early pregnancy loss, current evidence and clinical practice guidelines around management options, and provider and patient preferences for early pregnancy loss management.

Quality Improvement: Changing Patterns of Antibiotic Prophylaxis for Surgical Abortion.

OBJECTIVE: Postprocedure infection complicates nearly 5% of abortions. Multiple organizations endorse prophylactic antibiotics to reduce infection risk with surgical abortion, but the adherence rate remains unknown for women who obtain antibiotics at a pharmacy and take them at home before their procedure. Our objective was to evaluate the effect of quality improvement interventions on antibiotic utilization and preoperative documentation for women undergoing surgical abortion at our academic institution. METHODS: An initial quality evaluation of antibiotic utilization by women who had abortions in our operating room between April 2012 and June 2013 revealed suboptimal antibiotic adherence and poor physician documentation. To address these issues, we recommended patients to fill prescriptions at the pharmacy located in the same building as our clinic and created a standard preoperative template for the medical record. We reexamined outcomes for women having abortions from April 2014 to June 2015. RESULTS: Antibiotic adherence increased from 81% to 90% (p < .001). The proportion of patients not receiving antibiotics decreased from 2.4% to 0.5% (p = .01). Adherence documentation rates improved from 69% to 99% (p < .001). CONCLUSIONS: Using an easily accessible pharmacy and a standard preoperative template improves utilization of prophylactic antibiotics for patients undergoing abortions in the operating room.