Research roundup: June 2020 edition

Improved access to abortion care during the COVID-19 pandemic through implementation of a no-test protocol for medication abortion, use of Lactin-V in treatment of recurrent bacterial vaginosis, importance of expanded access to postpartum contraceptive options to improve both maternal and fetal outcomes, and more.

by Colleen Denny, MD and Emma Gilmore, MD

published 06/30/20

1. Sexual Health in the SARS-COV-2 Era

While much of the initial reporting regarding the SARS-CoV-2 virus and its associated illness COVID-19 focused on the nature of the illness itself and measures that could be taken to reduce its transmission, there has been less attention paid to the longer-term interaction between the pandemic and patients' sexual behavior. In this review, the authors point out that sexual expression plays an important role in many people's lives, and that complete sexual abstinence is not a reasonable or mentally healthy approach for many individuals. While current understanding of the virus indicates that transmission mainly occurs through aerosols or fomites, it is unclear whether semen, vaginal secretions, feces or urine could also allow transmission; accordingly, all in-person sexual encounters likely involve risk for contracting COVID-19. The authors encourage providers to discuss safe sex practices with their patients particularly in light of COVID-19, including masturbation and virtual sexual encounters, with attention paid to aspects of privacy with digital platforms. For patients pursuing in-person encounters, providers can discuss possible ways to mitigate infection risk, including showering, limiting contact with secretions, and considering masking. The authors also provide a table to guide healthcare providers' discussions with patients.

2. Commentary: No-test medication abortion: A sample protocol for increasing access during a pandemic and beyond

The COVID-19 pandemic has affected many healthcare models, including patients’ access to safe and timely abortion services. In this commentary, the authors discuss a modified “no-test” model for providing medication abortion during COVID-19 while minimizing in-person patient interaction with the health care system as much as is safely possible. They describe their protocol for determining gestational age, ectopic pregnancy risk factors, or other contraindications to medication abortion using the patient’s reported history alone; patients who have a sure last menstrual period (LMP) dating them at <= 77 days and have no risk factors or contraindications to medical abortion are candidates for this protocol. Eligible candidates receive standard medications for medication abortion (mifepristone and misoprostol), with a second dose of misoprostol to be used in all cases of pregnancies >63 days gestation or if there is suspected incomplete abortion after the standard dosing. Patients also receive home pregnancy tests to take at home 4 weeks after using the misoprostol, with instructions to call providers for a positive result. Blood typing is not recommended for pregnancies <70 days, or for patients who have a known positive blood type or who have completed childbearing. While this protocol is a significant change from pre-COVID standards of care that relied on in-person ultrasound dating, a “no-test” protocol is an evidence-based approach that maintains patient safety while allowing time-sensitive access to abortion care during a pandemic.

3. Follow-up strategies to confirm the success of medical abortion of pregnancies up to 10 weeks’ gestation: a systematic review with meta-analyses

Medical abortion using misoprostol and mifepristone is widely acknowledged to be a safe and acceptable practice up until 10 weeks of gestation with a small (1%) risk of a continuing pregnancy. Requiring in-person follow up to confirm pregnancy termination limits access to medication abortions. Additionally, data suggests that many patients do not present to their follow-up appointment. The authors of this study performed a meta-analysis to assess medication abortion follow-up methods: in-person as compared to virtual, along with comparing home pregnancy tests of varying sensitivity, from low to high. Overall, 4 studies were included with a total of 5,761 patients. Authors found that remote follow up did not differ significantly from in-person assessment, and in fact patients preferred to follow up remotely. Furthermore, when comparing home pregnancy tests of differing sensitivity, lower sensitivity pregnancy tests appeared to be sufficient for evaluation and led to fewer clinic visits for erroneously positive results. The authors note that although the quality of some of their analyzed evidence was low, their overall findings suggest large benefits to remote follow up and the expanded access that it can offer.

4. The concentration of fetal red blood cells in first-trimester pregnant women undergoing uterine aspiration is below the calculated threshold for Rh sensitization

Alloimmunization, or Rh sensitization, to Rh-D antigen is an important concern for patients with Rhesus (Rh)-negative blood types during pregnancy, as the development of maternal Anti-D immunoglobins after exposure can threaten the survival of current or future pregnancies. Administration of exogenous Rh immunoglobulin (Rhogam) to Rh-negative pregnant patients can prevent alloimmunization, but there is insufficient high-quality evidence to determine what level of exposure to fetal Rh-D antigen causes alloimmunization. Blanket provision of exogenous Rh immunoglobulin to all pregnant patients with Rh-negative blood types are often recommended but depletes a limited blood product resource and requires additional blood tests and waiting time for patients with bleeding in pregnancy. In this article, the authors set out to determine whether alloimmunization would be expected after termination of a first-trimester pregnancy. They used the existing literature to calculate the likely minimal concentration of fetal blood cells in the maternal circulation required for alloimmunization, estimating it at 250 fetal red blood cells (RBCs) per 10 million total RBCs. They then validated a flow cytometry assay to accurately estimate fetal blood cell counts and used this method with a cohort of 37 patients undergoing first-trimester abortion. All patients were found to have fetal RBC counts significantly below the threshold required for Rh sensitization. While larger studies are needed, this article provides high-quality evidence that providers may consider foregoing Rh immunoglobulin administration to patients who terminate, miscarry, or have bleeding during first trimester pregnancies.

5. COVID-19 and Family Planning Services FAQ

During the COVID-19 pandemic many clinic practices have shifted towards telehealth options and virtual health visits. This has a profound effect on family planning services which are often time-sensitive and may require an in-person procedure. This guide for providers as they care for patients in this new era, maintained by the Family Planning National Training Center (FPNTC), provides updated resources and answers to frequently asked questions about providing family planning services during COVID-19. The questions cover issues such as blood pressure checks prior to initiating estrogen-containing contraceptives, remote evaluation for sexually transmitted infections, and self-administration of the shot (Depo-Provera). The site also features links to fact sheets and online resources that provide evidence for their recommendations. This is a highly useful resource for providers who wish to continue offering high-quality family planning care using telehealth.

6. COVID-19 FAQs for Obstetrician–Gynecologists, Gynecology

Due to providers’ rapidly changing understanding of COVID-19 and its effects on practice and patient care, ACOG has convened multiple Task Forces to assemble a list of frequently asked questions for gynecologic issues. The FAQs include specific sections on abortion care and specify that due to time-sensitivity, abortion is not an elective service. Furthermore, contraception (including emergency contraception) is an essential service that can and should be provided using telehealth and virtual visits. There are also recommendations with regard to telemedicine follow up and strategies for providing counseling, signing consent forms and administering medication abortions without in-person visits. This resource also provides information on general preoperative screening and postoperative care for all gynecologic patients. The questions and answers, along with the list of resources and associated studies, are frequently updated in order to reflect the changes in the field’s understanding of COVID-19. This is a useful tool for all practicing gynecologists in order to better inform patient care during this unprecedented time.

7. Randomized Trial of Lactin-V to Prevent Recurrence of Bacterial Vaginosis

Bacterial vaginosis (BV) is common, affecting up to an estimated 50% of reproductive age women, and is a leading cause of health care visits among this patient group. Even after treatment, a large percentage of patients will have a recurrence of symptomatic BV within three months. In this randomized placebo-controlled controlled trial, the authors investigated whether treatment with Lactin-V, a naturally occurring vaginal strain of lactobacillus crispatus, would reduce the recurrence of BV after standard of care antibiotic treatment. The authors recruited 228 patients after their initial BV diagnosis and metronidazole treatment, and randomized in a 2:1 ratio of Lactin-V versus placebo. After 12 weeks, the investigators found BV recurrence in 45% of the placebo group but only 30% of the treated group, a statistically significant difference. For providers seeing patients with recurrent BV, supplementation with vaginal Lactin-V in addition to standard metronidazole treatment may decrease the likelihood of subsequent recurrence.

8. Coverage of immediate postpartum long-acting reversible contraception has improved birth intervals for at-risk populations

Short interpregnancy intervals (IPIs), variably defined, have been associated with increased risk of maternal health complications such as obesity, gestational diabetes, as well as adverse pregnancy outcomes such as prematurity and low birth weight. The majority of these short IPI pregnancies are unplanned. In this historical cohort study, the authors examined how the expansion of Medicaid in South Carolina to cover immediate postpartum long-acting reversible contraception (LARC) impacted uptake of LARC in different populations as well as its effect on short IPI. They found that in the years following the Medicaid expansion, immediate postpartum LARC uptake increased overall and particularly among patients with high-risk pregnancies and/or inadequate prenatal care and patients living in metropolitan areas. They also noted that immediate postpartum LARC use was associated with a lower risk of short IPI. These findings argue for the importance of making all postpartum contraception options, including LARC, easily available to patients to improve maternal and child health outcomes.

9. Impact of Combined Hormonal Contraceptive Use on Weight Loss: A Secondary Analysis of a Behavioral Weight‐Loss Trial

Weight loss, particularly maintenance of weight loss, is an issue of high importance for many individuals who use combined hormonal contraceptives (CHCs), particularly given the high rate of obesity in the United States. Estrogen and progesterone are known to affect metabolism in different ways, and progestins in particular are shown to increase appetite and may lead to weight gain. Researchers at the University of Colorado studied the interaction between CHCs and participants’ maintenance of weight loss over an 18-month period. A secondary analysis was performed on patients who underwent weight loss interventions, specifically a reduced-calorie diet and behavioral group support. 17 (15%) were CHC users, either the pill or vaginal ring, and this group was compared to non-CHC users. Participants’ weight loss was analyzed at 6 months, and all participants lost weight during this time. However, at 18 months, CHC users had regained almost all initial weight loss while non-CHC users had maintained their weight loss. Although this study suggests new findings with regard to weight loss and contraceptives, it should be interpreted with caution given the small sample size. Further research is needed to better understand the relationship between CHCs and weight loss, along with the possible mechanisms behind this difference.

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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