Telemedicine Follow-up After Medication Management of Early Pregnancy Loss.

Objective: Our objective was to evaluate the feasibility of a new protocol for telemedicine follow-up after medication management of early pregnancy loss. Study Design: The study was designed to assess the feasibility of planned telemedicine follow-up after medication management of early pregnancy loss. We compared these follow-up rates with those after planned in-person follow-up of medication management of early pregnancy loss and planned telemedicine follow-up after medication abortion. We conducted a retrospective cohort study, including patients initiating medication management of early pregnancy loss <13w0d gestation and medication abortion ≤10w0d with a combination of mifepristone and misoprostol between April 1, 2020, and March 28, 2021. As part of a new clinical protocol, patients could opt for telemedicine follow-up one week after treatment and a home urine pregnancy test 4 weeks after treatment. Our primary outcome was completed follow-up as per clinical protocol. We also examined outcomes related to complications across telemedicine and in-person follow-up groups. Results: Of patients reviewed, 181 were eligible for inclusion; 75 had medication management of early pregnancy loss, and 106 had medication abortion. Thirty-six out of 75 patients elected for telemedicine follow-up after early pregnancy loss. Of patients scheduled for telemedicine follow-up, 29/36 (81%, 95% CI: 64-92) with early pregnancy loss and 64/69 (93%, 95% CI: 84-98) undergoing medication abortion completed follow-up as per protocol (p = 0.06). Completed follow-up was also similar among patients undergoing medication management of early pregnancy loss who planned for in-person follow-up (p = 0.135). Complications were rare and did not differ across early pregnancy loss and medication abortion groups. Conclusions: Telemedicine follow-up is a feasible alternative to in-person assessment after medication management of early pregnancy loss.

Exploring Reasons for Loss to Follow-up in Pregnancy of Unknown Location: A Mixed-Methods Study.

Objective: To quantify proportions of loss to follow-up in patients presenting with a pregnancy of unknown location and explore patients' perspectives on follow-up for pregnancy of unknown location. A pregnancy of unknown location is a scenario in which a patient has a positive pregnancy test but the pregnancy is not visualized on transvaginal ultrasound. Study Design: We conducted a retrospective cohort study of patients with pregnancy of unknown location who presented to an urban academic emergency department or complex family planning outpatient office. We sought to calculate the proportion of patients lost to follow-up, defined as inability to contact the patient within 2 weeks. We then conducted focus groups of patients diagnosed with a pregnancy of unknown location. We used thematic analysis to identify themes related to follow-up. Results: We reviewed 464 charts of patients diagnosed with pregnancy of unknown location. The median age in this cohort was 27 with most patients identifying as Black (80%, n = 370) and using public insurance (67%, n = 315). When looking at loss to follow-up rates, Black patients experienced loss to follow-up (20%, n = 72) more often than White patients (4%, n = 2; p = 0.003). Focus group participants had a mean age of 31.8+/-4.8, and the majority were of Black race (n = 16, 72.7%). Participants identified barriers to follow-up including the long duration of management, general inconvenience, and poor communication with their health care team. Participants felt a burden of responsibility to learn about their condition and to self-advocate for their follow-up and communication of results. Conclusions: These data indicate that Black patients are more likely to experience loss to follow-up compared with White patients during monitoring for pregnancy of unknown location. Patients identified many barriers to follow-up and felt that successful follow-up required substantial self-efficacy.

High-Volume Surgeons and Reducing Racial Disparities in Route of Hysterectomy.

STUDY OBJECTIVE: To examine racial disparities in route of hysterectomy and perioperative outcomes before and after expansion of high-volume minimally invasive surgeons (>10 minimally invasive hysterectomies (MIH)/year) DESIGN: Retrospective cohort study SETTING: Multi-center academic teaching institution PATIENTS: All patients who underwent a scheduled hysterectomy for benign indications during 2018 (pre-intervention) and 2022 (post-intervention) INTERVENTIONS: Recruitment of Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS)- trained faculty and increased surgical training for academic specialists in obstetrics and gynecology occurred in 2020. MEASUREMENTS AND MAIN RESULTS: Patients in the pre-intervention cohort (n=171) were older (median age 45 years vs. 43 years, p=0.003) while patients in the post-intervention cohort (n=234) had a higher burden of comorbidities (26% ASA class III vs. 19%, p=0.03). Uterine weight was not significantly different between cohorts (p=0.328). Between the pre-intervention and post-intervention cohorts, high-volume minimally invasive surgeons increased from 27% (n=4) to 44% (n=7) of those performing hysterectomies within the division and percentage of hysterectomies performed via minimally invasive route increased (63% vs. 82%, p<0.001). In the pre-intervention cohort, Black patients had a lower percentage of hysterectomies performed via minimally invasive route compared to White patients (Black = 56% MIH vs. White = 76% MIH, p=0.014). In the post-intervention cohort, differences by race were no longer significant (Black = 78% MIH vs. White = 87% MIH, p= 0.127). There was a significant increase (22%) in MIH for Black patients between cohorts (p<0.001). After adjusting for age, BMI, ASA class, prior surgery, and uterine weight, disparities by race were no longer present in the post-intervention cohort. Perioperative outcomes including length of stay (p<0.001), infection rates (p=0.002) and blood loss (p=0.01) improved post-intervention. CONCLUSION: Increasing FMIGs-trained gynecologic surgeons and providing more opportunities in robotic/laparoscopic training for academic specialists may improve access to MIH for Black patients and reduce disparities.

Patient Preferences for Immediate Compared With Delayed Postpartum Intrauterine Device Placement.

OBJECTIVE: To use choice-based conjoint survey methodology to evaluate patient values and decision making regarding immediate compared with delayed placement of postpartum intrauterine devices (IUDs). METHODS: We conducted a cross-sectional study in which we surveyed 200 nonpregnant, parous patients. Participants chose between hypothetical postpartum IUDs varying in multiple attributes (hormonal or nonhormonal IUD type, placement timing, 1-year efficacy, expulsion risk, risk of lost strings, and malposition risk). The primary outcome was preference for immediate compared with delayed postpartum IUD placement and importance of placement timing relative to other attributes. Secondarily, we evaluated whether demographic and neighborhood characteristics were associated with timing preference and attribute importance. RESULTS: We included 190 participants for analysis. Most participants (62.6%) preferred delayed placement. There was no significant difference in timing preference by race (P=.28) or block-level Area Deprivation Index score (P=.27). Patients who preferred immediate placement were more likely to have public insurance than private insurance (70.4% vs 29.6%, P=.04); however, the majority of patients (55.1%) with public insurance still preferred delayed placement. Attributes of IUD type, malposition risk, 1-year efficacy, and expulsion risk all had greater effects on patient decision making than placement timing. There was no difference in attribute importance by race (P=.30), Area Deprivation Index score (P=.88), or insurance type (P=.22). CONCLUSION: Patients preferred the higher efficacy and lower complication rates of delayed postpartum IUD placement over the convenience of immediate placement. Insurance considerations may affect these timing preferences. There was no difference in attribute importance between demographic groups or based on neighborhood-level factors, indicating that, although both immediate and delayed postpartum IUD placement should be offered, counseling should not vary according to individual demographic characteristics.

Outcomes After Induction of Labor Compared With Dilation and Evacuation for the Management of Rupture of Membranes in the Second Trimester.

Previable and periviable rupture of membranes is associated with significant morbidity for the pregnant patient. For those who have a choice of options and undergo active management, it is not known how the risks of induction of labor compare with those for dilation and evacuation (D&E). We performed a retrospective cohort study of patients with rupture of membranes between 14 0/7 and 23 6/7 weeks of gestation who opted for active management. Adverse events (52.2% vs 16.9%, P <.01) and time to uterine evacuation greater than 24 hours (26.7% vs 9.6%, P =.01) were more common among patients undergoing induction of labor. In a multivariable regression, induction of labor was an independent risk factor for complications (odds ratio 5.70, 95% CI, 2.35-13.82) compared with D&E. Severe complications were rare across both groups (4.4% for patients undergoing induction vs 2.6% for D&E, P =.63). Given the differing risks by termination method, access to D&E is an important treatment option for this patient population.

"I Wasn't Expecting That Question": Responses to Requests for Abortion Referral at College Student Health Centers.

BACKGROUND: Women 18-24 years of age have the highest proportion of unintended pregnancies of any age group, and thus represent a significant population in need of abortion services. Prior research indicated that only half of college student health centers provide appropriate abortion referrals. Our objective was to better understand the referral experience and barriers to abortion referral at college student health centers. PROCEDURES: We conducted a "secret caller" study at all 4-year colleges in Pennsylvania between June 2017 and April 2018, using a structured script requesting abortion referral. Calls were transcribed, coded using an iteratively developed codebook, and analyzed for themes related to barriers and facilitators of abortion referral. MAIN FINDINGS: A total of 202 completed transcripts were reviewed. Themes that emerged were knowledge, experience, and comfort with abortion referral; support, empathy, and reassurance; coercion; misleading language; questioning the caller's autonomy; and institutional policy against referral. Most staff lacked knowledge and comfort with abortion referral. Although some staff members made supportive statements toward the caller, others used coercive language to try to dissuade the caller from an abortion. Many staff cited religious institutional policies against abortion referral and expressed a range of feelings about such policies. CONCLUSIONS: Abortion referrals at student health centers lack consistency. Staff members frequently did not have the knowledge needed to provide appropriate abortion referrals, used coercive language in responding to requests for referrals, and perpetuated abortion stigma. Some health staff used coercive or evasive language that further stigmatized the caller's request for an abortion referral. College health centers should improve training and resources around abortion referral to ensure they are delivering appropriate, high-quality care.

Trust in provider and stigma during second-trimester abortion.

OBJECTIVE: To determine whether trust in the provider and sociodemographics are associated with individual-level abortion stigma. METHODS: We performed a cross sectional and exploratory study design using secondary analysis of a randomized trial that enrolled participants undergoing second trimester abortion. We collected baseline survey data from 70 trial participants to assess stigma (Individual Level of Abortion Stigma scale, ILAS; range 0-4), trust in provider (Trust in Physician scale; range 1-5), anxiety, depression, and sociodemographics. We performed multiple linear regression, for which ILAS score was the outcome of interest. Univariate associations were used to inform the regression model. RESULTS: The mean abortion stigma score was at the low end of the ILAS at 1.21 (range 0.2-2.8, SD 0.66). Age, race, income, BMI, parity, gestational age at time of abortion, and reasons for ending the pregnancy were not significantly associated with the ILAS score. Higher trust in provider scores were (m 4.0, SD 0.49) and inversely related to the ILAS score, even after adjustment for confounders (ß -0.02, CI -0.03 to -0.004, p = 0.013). Screening positive for anxiety or depression was associated with a higher ILAS score ((ß 0.48, CI 0.10, 0.90, p = 0.015); (ß = 0.27 CI -0.097, 0.643)), while cohabitation was associated with lower ILAS score (ß -0.44, CI -0.82 to -0.57, p = 0.025). CONCLUSIONS: Trust in an abortion provider, anxiety, depression, and cohabitation are associated with abortion stigma among people seeking second trimester abortion care. Interventions that improve trust in a provider may be an area of focus for addressing abortion stigma. Future research should confirm these findings in larger populations and across diverse locations and demographics and to conduct qualitative research to understand what patients perceive as trust-promoting behaviors and words during abortion encounters.

Telephone-Based Intervention to Improve Family Planning Care in Pregnancies of Unknown Location: Retrospective Pre-Post Study.

BACKGROUND: Patients followed for a pregnancy of unknown location are generally followed by a team of clinicians through telephone calls, and their contraceptive needs at the time of pregnancy resolution may not be addressed. OBJECTIVE: This study aimed to assess contraceptive counseling and contraceptive uptake before and after a telephone-based intervention. METHODS: This was a retrospective pre-post study assessing pregnancy intendedness in patients with a pregnancy of unknown location and the proportion of patients who received contraceptive counseling and a contraceptive prescription before and after the initiation of a telephone-based intervention. We reviewed medical records 1 year before and 1 year after implementation of our intervention for demographic characteristics, pregnancy intendedness, pregnancy outcome, contraceptive counseling documentation, receipt of contraception, and repeat pregnancy within 6 months. We assessed the effects of an implementation strategy to address family planning needs once pregnancy was resolved by comparing the proportions of patients who were counseled and received contraception before and after our intervention was implemented. We performed logistic regression to identify associations between covariates and the outcomes of contraceptive counseling documentation and receipt of contraception. RESULTS: Of the 220 patients in the combined cohort, the majority were Black (161/220, 73%) and ultimately had a resolved pregnancy of unknown location (162/220, 74%), and the proportion of pregnancies documented as unintended was 60% (132/220). Before our intervention, 27 of 100 (27%) patients received contraceptive counseling, compared with 94 of 120 (78%) patients after the intervention (odds ratio [OR] 9.77, 95% CI 5.26-18.16). Before the intervention, 17 of 90 (19%) patients who did not desire repeat pregnancy received contraception, compared with 32 of 86 (37%) patients after the intervention (OR 2.54, 95% CI 1.28-5.05). Our postintervention cohort had an increased odds of receiving contraceptive counseling (OR 9.77, 95% CI 5.26-18.16) and of receiving a contraceptive prescription (OR 2.54, 95% CI 1.28-5.05) compared with our preintervention cohort. CONCLUSIONS: We found that over half of patients with a pregnancy of unknown location have an unintended pregnancy, and standardization of care through a telephone-based intervention improves contraceptive counseling and prescribing in patients with a resolved pregnancy of unknown location. This intervention could be used at any institution that follows patients with a pregnancy of unknown location remotely to improve care.

Evaluation of a decision aid for early pregnancy loss: A pilot randomized controlled trial in Philadelphia, Pennsylvania.

OBJECTIVES: To evaluate the effect of a decision aid on decisional conflict scale in patients choosing management for early pregnancy loss. STUDY DESIGN: We conducted a pilot randomized control trial to assess the effect of the Healthwise patient decision aid on decisional conflict scale in patients with early pregnancy loss as compared with a control website. Patients 18years and older were eligible if they had an early pregnancy loss between 5 and 12 completed weeks of gestation. Participants completed surveys at baseline, poststudy intervention, after consultation, and 1week postconsultation. Surveys assessed participant scores on the decisional conflict scale (scale 0-100), knowledge, assessment of shared decision-making, satisfaction, and decision regret. Our primary outcome was the poststudy-intervention decisional conflict scale score. RESULTS: From July 2020 through March 2021 we randomized 60 participants. After the intervention, the median decisional conflict scale score for the control group was 10 [0-30] and 0 [0-20] for the intervention group (p = 0.17). When assessing the decisional conflict scale subscales postintervention, the informed subscale for the control group was 16.7 [0-33.3] as opposed to 0 [0] for the patient decision aid group (p = 0.003). Knowledge remained significantly higher in the experimental arm from the postintervention to the 1-week follow-up. We found no differences between groups when assessing our other metrics. CONCLUSIONS: Use of a validated decision aid did not result in statistically significant differences in the total decisional conflict scale scores as compared with the control. Participants allocated to the intervention were more informed postintervention and had consistently higher knowledge scores. IMPLICATIONS: Use of a validated decision aid prior to early pregnancy loss management consultation did not affect overall decisional conflict but resulted in improved knowledge.

Characterizing Twitter Content About HIV Pre-exposure Prophylaxis (PrEP) for Women: Qualitative Content Analysis.

BACKGROUND: HIV remains a persistent health problem in the United States, especially among women. Approved in 2012, HIV pre-exposure prophylaxis (PrEP) is a daily pill or bimonthly injection that can be taken by individuals at increased risk of contracting HIV to reduce their risk of new infection. Women who are at risk of HIV face numerous barriers to HIV services and information, underscoring the critical need for strategies to increase awareness of evidence-based HIV prevention methods, such as HIV PrEP, among women. OBJECTIVE: We aimed to identify historical trends in the use of Twitter hashtags specific to women and HIV PrEP and explore content about women and PrEP shared through Twitter. METHODS: This was a qualitative descriptive study using a purposive sample of tweets containing hashtags related to women and HIV PrEP from 2009 to 2022. Tweets were collected via Twitter's API. Each Twitter user profile, tweet, and related links were coded using content analysis, guided by the framework of the Health Belief Model (HBM) to generate results. We used a factor analysis to identify salient clusters of tweets. RESULTS: A total of 1256 tweets from 396 unique users were relevant to our study focus of content about PrEP specifically for women (1256/2908, 43.2% of eligible tweets). We found that this sample of tweets was posted mostly by organizations. The 2 largest groups of individual users were activists and advocates (61/396, 15.4%) and personal users (54/396, 13.6%). Among individual users, most were female (100/166, 60%) and American (256/396, 64.6%). The earliest relevant tweet in our sample was posted in mid-2014 and the number of tweets significantly decreased after 2018. We found that 61% (496/820) of relevant tweets contained links to informational websites intended to provide guidance and resources or promote access to PrEP. Most tweets specifically targeted people of color, including through the use of imagery and symbolism. In addition to inclusive imagery, our factor analysis indicated that more than a third of tweets were intended to share information and promote PrEP to people of color. Less than half of tweets contained any HBM concepts, and only a few contained cues to action. Lastly, while our sample included only tweets relevant to women, we found that the tweets directed to lesbian, gay, bisexual, transgender, queer (LGBTQ) audiences received the highest levels of audience engagement. CONCLUSIONS: These findings point to several areas for improvement in future social media campaigns directed at women about PrEP. First, future posts would benefit from including more theoretical constructs, such as self-efficacy and cues to action. Second, organizations posting on Twitter should continue to broaden their audience and followers to reach more people. Lastly, tweets should leverage the momentum and strategies used by the LGBTQ community to reach broader audiences and destigmatize PrEP use across all communities.

Perceptions of HIV risk screening strategies among patients seeking abortion, contraception, and pregnancy loss management in the United States.

OBJECTIVES: Women make up nearly a fifth of new human immunodeficiency virus (HIV) infections yearly in the United States, more than half of which could have been prevented with broader use of HIV pre-exposure prophylaxis (PrEP). We aimed to qualitatively assess (1) acceptability of an HIV risk screening strategy and PrEP provision in a family planning setting, and (2) the influence of family planning visit type (abortion, pregnancy loss management, or contraception) on HIV risk screening acceptability. STUDY DESIGN: Guided by the P3 (practice-, provider-, and patient-level) model for preventive care interventions, we conducted three focus group discussions including patients who had experienced induced abortion, early pregnancy loss (EPL), or contraception care. We developed a codebook of a priori and inductive concepts, and categorized themes by practice, provider, and patient considerations. RESULTS: We included 24 participants. Practice-level considerations included overall positive feelings about being screened for PrEP eligibility during family planning visits, though some expressed reservations about screening during EPL visits. Provider-level themes included the concept of screening tools as entry points into conversation and education, and the importance of nonjudgment in discussing sexually transmitted infection (STI) prevention. Participants often had to initiate STI prevention discussions and felt that contraception was overemphasized by their providers compared with STI prevention and PrEP care. Patient-level themes included the stigma of STIs and oral PrEP, and the dynamic nature of STI risk. CONCLUSIONS: Participants in our research had genuine interest in learning about PrEP during family planning visits. Findings from our research support the consistent inclusion of STI prevention education into family planning clinical practice using patient-centered STI screening methods. IMPLICATIONS: Family planning encounters, including visits for contraception and abortion, are generally appropriate times to discuss HIV PrEP. Patient-centered conversations are an important adjunct to HIV risk screening tools.

Exploring technology-based interventions to improve oral contraceptive pill adherence: a cross-sectional survey.

PURPOSE: To assess the resources that oral contraceptive pill (OCP) users currently use and wish to use after missing pills. MATERIALS AND METHODS: People 18-44 years old with a OCP prescription were emailed a cross-sectional survey to assess how they obtain information about managing missed pills, what information they would prefer to access, and whether they would use additional information if it were available. We performed a logistic regression and a dominance analysis to compare independent predictors of desire for a technological resource at the time of missed pills. RESULTS: We received 166 completed surveys. Nearly half of participants (47%, n = 76, 95% CI 39.0-54.4%) did not seek information about managing their missed pills. When missing a pill, more patients preferred non-technology-based information (57.1%, n = 93, 95% CI 49.3-64.5%) over technology-based information (43%, n = 70, 95% CI 35.5-50.7%). Most reported they would appreciate more information at the time of missed pills (76%, n = 124, 95% CI 68.9-82.0%). The strongest predictors for desire for technology-based information were: current use of technology, lower parity, white race, and higher educational attainment. CONCLUSIONS: This study indicates that most OCP users would utilise additional information at the time of a missed pill if they had access to it and that they desire information in varying formats.

Patients desire more educational information at the time of missed oral contraceptive pills, and preferences are varied regarding the format of patient information. Implementation of high-quality counseling with oral contraceptive pills requires a broad range of educational materials as well as provider education.

Reduction of racial disparities in urine drug testing after implementation of a standardized testing policy for pregnant patients.

BACKGROUND: Drug use during pregnancy can have implications for maternal and fetal morbidity and mortality and legal ramifications for patients. The American College of Obstetricians and Gynecologists guideline states that drug screening policies during pregnancy should be applied equally to all people and notes that biological screening is not necessary, stating that verbal screening is adequate. Despite this guidance, institutions do not consistently implement urine drug screening policies that reduce biased testing and mitigate legal risks to the patient. OBJECTIVE: This study aimed to evaluate the effects of a standardized urine drug testing policy in labor and delivery on the number of drug tests performed, self-reported racial makeup of those tested, provider-reported testing indications, and neonatal outcomes. STUDY DESIGN: This was a retrospective cohort study. A urine drug screening and testing policy was introduced in December 2019. The electronic medical record was queried for the number of urine drug tests performed on patients admitted to the labor and delivery unit from January 1, 2019, to April 30, 2019. The number of urine drug tests performed between January 1, 2019, and April 30, 2019, was compared with the number of urine drug tests performed between January 1, 2020, and April 30, 2020. The primary outcome was the proportion of urine drug tests performed based on race before and after the implementation of a drug testing policy. The secondary outcomes included total number of drug tests, Finnegan scores (a proxy for the neonatal abstinence syndrome), and testing indications. To understand perceived testing indications, pre- and postintervention provider surveys were administered. Chi-square and Fisher exact tests were used to compare categorical variables. The Wilcoxon rank-sum test was used to compare nonparametric data. The Student t test and 1-way analysis of variance were used to compare means. Multivariable logistic regression was used to construct an adjusted model that included covariates. RESULTS: In 2019, Black patients were more likely to undergo urine drug testing than White patients, even after adjusting for insurance status (adjusted odds ratio, 3.4; confidence interval, 1.55-7.32). In 2020, there was no difference in testing based on race after adjusting for insurance status (adjusted odds ratio, 1.3; confidence interval, 0.55-2.95). There was a reduction in the number of drug tests performed between January 2019 and April 2019 compared with between January 2020 and April 2020 (137 vs 71; P<.001). This was not accompanied by a statistically significant change in the incidence of neonatal abstinence syndrome measured by mean Finnegan scores (P=.4). Before the implementation of a drug testing policy, 68% of providers requested patient consent for testing; after the implementation of a drug testing policy, 93% requested patient consent for testing (P=.002). CONCLUSION: The implementation of a urine drug testing policy improved consent for testing and reduced disparities in testing based on race and the overall rate of drug testing without affecting neonatal outcomes.

Achieving Equity in Postpartum Contraception Access.

Equitable access to contraception and contraceptive education has the potential to mitigate health disparities related to unintended pregnancy. Pregnancy and the postpartum window frequently offer reduced insurance barriers to healthcare, increased interaction with healthcare systems and family planning providers, and an opportune time for many individuals to receive contraception; however, there are additional considerations in method type for postpartum individuals, and contraceptive counseling must be thoughtfully conducted to avoid coercion and promote shared decision-making. This commentary reviews method-specific considerations and suggests priorities for achieving equity in postpartum contraceptive access.

Provision of HIV preexposure prophylaxis to female patients seeking family planning services in the United States.

OBJECTIVE: We conducted a scoping review to assess barriers to and facilitators of integrating HIV preexposure prophylaxis (PrEP) and family planning (FP) at the patient, provider, and implementation levels, and to identify gaps in knowledge. METHODS: We conducted a search of five bibliographic databases from database inception to March 2022: PubMed, CINAHL, Embase, Web of Science and Scopus. Two reviewers screened abstracts and full texts to determine eligibility based on a priori inclusion and exclusion criteria. We categorized studies by their relevance to patient, provider, and implementation barriers, and extracted data based on prespecified elements. RESULTS: Our initial search strategy yielded 1151 results, and 34 publications were included. Barriers to PrEP implementation in family planning settings included low PrEP knowledge among patients, hesitance to take PrEP due to perceived stigma, decreased willingness of providers unfamiliar with PrEP to prescribe PrEP, and limited financial and staffing resources that make prescribing and monitoring PrEP difficult. Facilitators included robust training for providers, stigma reduction efforts, leadership engagement, and increased resources specifically in settings with processes in place that ease the process of prescribing and monitoring PrEP. CONCLUSIONS: Advances in implementation strategy development, stigma reduction, and drug development will be essential to reinforcing PrEP care in family planning settings and thereby reducing the incidence of HIV in women through highly effective pharmacologic HIV prevention methods.

Medical management of early pregnancy loss is cost-effective compared with office uterine aspiration.

BACKGROUND: Early pregnancy loss, also referred to as miscarriage, is common, affecting approximately 1 million people in the United States annually. Early pregnancy loss can be treated with expectant management, medications, or surgical procedures-strategies that differ in patient experience, effectiveness, and cost. One of the medications used for early pregnancy loss treatment, mifepristone, is uniquely regulated by the Food and Drug Administration. OBJECTIVE: This study aimed to compare the cost-effectiveness from the healthcare sector perspective of medical management of early pregnancy loss, using the standard of care medication regimen of mifepristone and misoprostol, with that of office uterine aspiration. STUDY DESIGN: We developed a decision analytical model to compare the cost-effectiveness of early pregnancy loss treatment with medical management with that of office uterine aspiration. Data on medical management came from the Pregnancy Failure Regimens randomized clinical trial, and data on uterine aspiration came from the published literature. The analysis was from the healthcare sector perspective with a 30-day time horizon. Costs were in 2018 US dollars. Effectiveness was measured in quality-adjust life-years gained and the rate of complete gestational sac expulsion with no additional interventions. Our primary outcome was the incremental cost per quality-adjust life-year gained. Sensitivity analysis was performed to identify the key uncertainties. RESULTS: Mean per-person costs were higher for uterine aspiration than for medical management ($828 [95% confidence interval, $789-$868] vs $661 [95% confidence interval, $556-$766]; P=.004). Uterine aspiration more frequently led to complete gestational sac expulsion than medical management (97.3% vs 83.8%; P=.0001); however, estimated quality-adjust life-years were higher for medical management than for uterine aspiration (0.082 [95% confidence interval, 0.8148-0.08248] vs 0.079 [95% confidence interval, 0.0789-0.0791]; P<.0001). Medical management dominated uterine aspiration, with lower costs and higher confidence interval. The probability that medical management is cost-effective relative to uterine aspiration is 97.5% for all willingness-to-pay values of ≥$5600/quality-adjust life-year. Sensitivity analysis did not identify any thresholds that would substantially change outcomes. CONCLUSION: Although office-based uterine aspiration more often results in treatment completion without further intervention, medical management with mifepristone pretreatment costs less and yields similar quality-adjust life-years, making it an attractive alternative. Our findings provided evidence that increasing access to mifepristone and eliminating unnecessary restrictions will improve early pregnancy care.

Utility and Limitations of Human Chorionic Gonadotropin Levels for Remote Follow-up After Medical Management of Early Pregnancy Loss.

Early pregnancy loss can be treated medically with mifepristone followed by misoprostol, with ultrasonographic confirmation of pregnancy expulsion. Alternative strategies that ascertain treatment success remotely are needed. We compared percent decline in human chorionic gonadotropin (hCG) level with treatment success or failure between patients who received mifepristone pretreatment followed by misoprostol or misoprostol alone for early pregnancy loss between 5 and 12 weeks of gestation to determine a threshold decline that might predict success. Early pregnancy loss treatment success was associated with a greater percent hCG level decline compared with treatment failure, but no threshold was able to predict success. Additional research is needed to understand hCG trends after medical management of early pregnancy loss to develop reliable protocols for remote follow-up.