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Research roundup: July 2022 edition

Management of retained products of conception and a comparison of buccal and vaginal misoprostol for medication abortion, contraceptive values and preferences of adolescents and young adults, and more.

by Colleen Denny, MD and Emma Gilmore, MD

published 07/29/22

1. Expectant vs medical management for retained products of conception after medical termination of pregnancy: a randomized controlled study

Medication abortion using mifepristone and misoprostol is a safe and effective treatment for pregnancy termination in the first trimester. Complications are uncommon but may include retained products of conception after treatment. While a repeat dose of misoprostol is often recommended for this complication, the effectiveness of this management option is unclear. In this randomized controlled trial, the authors recruited 141 patients who had suspected retained products of conception on ultrasound after medication abortion at nine weeks of gestation or earlier. Half the patients received expectant management, while the others received 800mcg of sublingual misoprostol, and all patients subsequently underwent serial ultrasounds for up to six weeks as follow up. The authors found that there was not a significant difference in successful management between the misoprostol and expectant management arms, with 62% and 57% of patients successfully managed, respectively, and that there were no differences in adverse outcomes between the groups. Providers offering follow up visits after medication abortion can incorporate this data into their management plans for patients with retained products of conception, offering both non-surgical management options per patient preference.

2. Comparison of vaginal and buccal misoprosotol after mifepristone for medication abortion through 70 days of gestation: A retrospective chart review

Medication abortion using mifepristone and misoprostol is a safe and effective treatment for pregnancy termination in the first trimester and now accounts from more than half of all abortions in the US. While mifepristone is taken orally, misoprostol may be taken in several ways, with buccal and vaginal administration being the most common. In this retrospective cohort study, the authors examined whether vaginal versus buccal misoprostol administration was associated with higher rates of successful abortion. Among nearly 9,000 identified cases of medication abortion before 71 days’ gestation, the authors found that buccal misoprostol was associated with statistically significantly higher rate of successful medication abortion, with 97.7% efficacy versus 96.4% efficacy in the vaginal misoprostol group. However, the authors note that these differences do not reflect a clinically important difference, and that both methods are highly effective. Patient preference can be heavily factored into the decision about route of misoprostol administration.

3. Society of Family Planning clinical recommendation: Extended use of long-acting reversible contraception

Forms of long-acting reversible contraception (LARC) such as IUDs or etonogestrel implants, can provide highly effective, long-acting birth control. However, there are discrepancies between the FDA’s approval for duration of use for these LARCs and data showing the effectiveness of extended use of LARCs past these time points. In this clinical recommendation from the Society of Family Planning, the authors discuss that the 52mg LNG-IUDs (Mirena and Liletta) have high contraceptive effectiveness up to eight years, the copper IUD (Paragard) has high effectiveness up to 12 years, and the etonogestrel implant (Nexplanon) has high effectiveness up to five years. These recommendations are independent of BMI. There is not high-quality data to recommend extending the duration of use for the 19.5mg (Kyleena) and 13.5mg (Skyla) IUD, which are FDA-approved to five and three years, respectively.

4. Safety and effectiveness of self-managed medication abortion provided using online telemedicine in the United States: A population based study

As abortion access in many parts of the US becomes increasingly restricted or outright banned, more patients are considering self-managed medication abortion after obtaining medications via telemedicine. Compared to provider-managed medication abortion (which can also be via telehealth), providers and patients may have concerns about the safety and efficacy of this care model. This retrospective analysis included more than 3,000 patients who pursued medication abortion from a single online telemedicine service (Aid Access) and provided follow up data. In their analysis, the authors found that 96.4% of respondents reported successfully ending their pregnancies without further intervention. Serious adverse events were rare, at 1% total overall, and were more common in patients with pregnancies greater than 10 weeks’ gestation (2.8%). Overall, 98% of respondents felt satisfied with their experience. As telehealth for medication abortion comes under greater demand and greater scrutiny in response to abortion bans, this research suggests high rates of safety and efficacy for self-managed abortion.

5. Contraceptive values and preferences of adolescents and young adults: A systematic review

Adolescents and young adults (up to 25 years old) are a vulnerable population, and may experience higher rates of unintended pregnancy, higher risk pregnancies, and unmet needs for contraceptive services. To better understand the sexual and reproductive health needs of this age group, the authors of this article performed a systematic review of studies over a 15-year period that focused on contraception preferences in individuals aged 25 or younger. They reviewed a total of 55 studies from 16 different countries. The authors found that young people place a high value on privacy and autonomy, and that their social context also influences their beliefs and preferences regarding contraception. However, the studies did not describe gender-diverse participants, and only a small proportion of studies were conducted in low-income countries. Overall, these results contain important points for providers caring for this patient population, but also provide a limited perspective and indicate a need for further research in this area.

6. Trends in Emergency Contraceptive Use Among Adolescents and Young Adults, 2006–2017

Emergency contraception (EC) is an important set of medications that includes over-the-counter (OTC), progestin-containing EC pills (such as Plan B), prescription EC pills ulipristal acetate (ella), the copper IUD (Paragard), or an IUD with 52mg of levonorgestrel (Liletta or Mirena). EC may be utilized anytime someone has had unprotected or underprotected sex in the last five days and does not desire pregnancy. Starting in 2006, prescribing and age-related restrictions were removed from OTC Plan B, and by 2014 this medication and generic formats were made available OTC to purchasers of all ages. However, little is known about habits in location of purchasing after these changes were made, specifically regarding adolescents and young adults from 15 to 24 years old. The authors of this study used National Survey of Family Growth (NSFG) data to examine prevalence and purchasing trends of EC for sexually experienced females in this age group. They noted an increasing percentage of adolescents and young adults purchasing EC in pharmacies, while fewer patients obtained EC at family health clinics. However, less than 5% of providers are counseling this population about EC. These results suggest a need for improved counseling as adolescents and young adults are increasingly autonomous in their ability to obtain EC.

7. Society of Family Planning clinical recommendations: Contraception and abortion care for persons who use substances

Individuals who use substances have poorly understood reproductive and sexual health needs but are more vulnerable to adverse outcomes such as increased rates of sexually transmitted infections and unintended pregnancy. Previous studies also suggest that this population has a lower contraception-use rate than other people. Although there is a lack of robust evidence on individuals who use substances, the authors of this paper created a series of recommendations for providing contraception and abortion care for them, with a particular focus on patients who use opioids. The writers made sure to specify that these recommendations apply to all individuals who use substances and not just those who carry a diagnosis of substance use disorder. Screening for substance use is an important part of reproductive health care so that providers can offer resources and support. This guidance includes evidence-based information on outpatient abortion, anesthesia techniques, and management of maintenance for opioid use disorders such as methadone and buprenorphine. It also provides recommendations on pregnancy desire screening, contraceptive counseling, and shared-decision making. This paper is important and useful reading for those providing family planning services to any patients who use substances.

8. Intrauterine device-related uterine perforation incidence and risk (APEX-IUD): a large multisite cohort study

Perforation at time of IUD placement, when the IUD passes entirely or partially through the uterine wall, is a rare but known complication of IUD use and usually requires surgical management. In this sub-analysis of the APEX-IUD study, a large retrospective cohort study of more than 300,000 IUD users, the authors examined how postpartum status and breastfeeding at time of IUD placement affected perforation risk. The authors identified a total of more than 1,000 IUD perforations in the study cohort and determined that the five-year risk of perforation was lowest for non-postpartum individuals, at 0.29%, compared to 1.89% for individuals with an IUD placed between four days and six weeks postpartum. Among the postpartum cohort, the risk of perforation was 37% higher in breastfeeding individuals. However, the authors note that while the risks of IUD perforation are up to seven times higher for insertion postpartum when breastfeeding, perforation remains incredibly rare at all clinical time points. Providers offering postpartum IUD insertion should prioritize a patient’s timing preferences and risk of unintended pregnancy over small changes in perforation risk.

9. Association between menorrhagia and risk of intrauterine device–related uterine perforation and device expulsion: results from the Association of Uterine Perforation and Expulsion of Intrauterine Device study

Heavy or prolonged menstrual bleeding, also called menorrhagia, can profoundly affect the quality of life of those who experience it. Levonorgestrel intrauterine devices (LNG IUDs) are an approved treatment method for menorrhagia, but it has been suggested that heavy bleeding can increase the risk of IUD expulsion. The APEX-IUD study was designed to evaluate multiple IUD outcomes across differing patient populations in a cohort of more than 326,000 individuals who had used an IUD. For one series of outcomes, the authors investigated the association between menorrhagia and IUD perforation or expulsion. For this analysis, they focused on more than 228,000 subjects who had not had a delivery in the preceding 12 months, to eliminate any possible confounders created by the postpartum state. The authors found that individuals with heavy menstrual bleeding have a three-times increased risk of uterine expulsion, and a small increase in their risk of uterine perforation, although the absolute risk remained very low. These findings suggest that providers should maintain awareness of the increased risk of expulsion for patients with menorrhagia and incorporate this into their counseling.

Colleen Denny, MD, is an attending ObGyn at Bellevue Hospital in New York City, where she is the Medical Director of the Women's Clinic, and a clinical assistant professor with the NYU School of Medicine. She enjoys providing care for patients in all phases of life and is especially interested in issues related to contraception access and public health. Outside of work, she’s a runner, a dancer, and a bit of a crossword puzzle nerd.
Emma Gilmore is a fellow in Complex Family Planning at the University of Pennsylvania. She completed her residency in Obstetrics and Gynecology at New York University. She's passionate about reproductive rights, medical education, and combating health care disparities, particularly in sexual and reproductive health. In her free time, she can be found taking her dog on walks around the beautiful parks in and around Philadelphia.
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