Research roundup: October 2023 edition

Pain management in abortion care, risk of Rh sensitization with abortion before 12 weeks’ gestation, and contraception information on TikTok.

by Colleen Denny, MD

published 10/31/23

1. Induced Abortion and the Risk of Rh Sensitization

Patients who have RhD-negative red blood cells may develop anti-D antibodies during pregnancy if they are exposed to sufficient RhD-positive fetal red blood cells, a process called alloimmunization. This may cause potential complications for the current and future pregnancies. To prevent alloimmunization, RhD-negative pregnant patients historically received Rh immunoglobulin, “Rhogam”, at any time in pregnancy where fetal blood exposure is possible, including after abortion. However, population-level data and increasing bench research suggest that alloimmunization is rare for patients undergoing abortion before 12 weeks’ gestation. In this multinational observational prospective study, the authors measured circulating levels of fetal red blood cells in maternal blood samples in more than 500 patients undergoing procedural or medication abortion before 12 weeks’ gestation. They determined that 99.8% of all patients did not exceed the fetal red blood cell threshold necessary for maternal alloimmunization after abortion; one patient was noted to have an elevated fetal red blood cell count before an abortion that remained elevated afterward. The authors conclude that this study adds to the growing literature demonstrating that induced first-trimester abortion is not a risk factor for Rh alloimmunization and that blood type testing and management with Rh immunoglobulin is unnecessary before 12 weeks gestation.

2. Public perceptions of abortion complications

Modern abortion methods are extremely safe, with low rates of short-term complications such as heavy bleeding or infection, and even lower rates of long-term complications such as affected future fertility or death. However, public understanding of this safety profile may not reflect these statistics. In this cross-sectional online survey, researchers queried more than 1,000 adults about their understanding of various complications associated with abortion. The authors found that participants answered that all listed abortion complications occurred more frequently than the known incidence, with over 40% of participants reporting that bleeding and infection occurred occasionally or frequently and over 60% of participants reporting that depression and anxiety occurred occasionally or frequently after abortion. Several complications not associated with abortion at all, including hair loss, breast cancer, or cosmetic disfigurement, were endorsed by a majority of participants as occurring at least rarely, and approximately a quarter of participants reported that death occurred after abortions at least 5% of the time. The authors conclude that misinformation about abortion safety is common and greatly overestimates the true risks and call for targeted outreach efforts to promote accurate portrayals of the safety of abortion care.

3. Contraception After Abortion

Many patients undergoing spontaneous or induced abortion may desire to prevent or delay subsequent pregnancy. Given that ovulation may occur as soon as 8 days after abortion and that about a third of patients resume sexual activity sooner than two weeks after abortion, contraception counseling and provision at the time of abortion services provides an important opportunity to help improve access and convenience for patients who wish to prevent pregnancy. In this clinical review, the authors discuss several aspects of contraception provision after abortion, beginning with providing patient-centered, non-coercive counseling. They review combined hormonal contraception options, progestin-only pills, implants, IUDs, barrier methods, permanent contraception, fertility awareness methods, emergency contraception, and lactational amenorrhea in the particular context of both medication and procedural abortion. This review provides clear, up-to-date clinical guidance for clinicians providing abortion and contraception care.

4. Effects of the Dobbs v Jackson Women's Health Organization Decision on Obstetrics and Gynecology Graduating Residents' Practice Plans

The Supreme Court decision in Dobbs v Jackson Women’s Health Organization in June 2022 has led to significant abortion restrictions or outright abortion bans in many states in the US. These changes have significant adverse effects on patients seeking comprehensive reproductive health care but also have the potential to affect health care professionals who must decide whether and how to practice evidence-based medicine in regions with these restrictions. In this mixed-methods survey study, the authors queried resident physicians imminently graduating from OB-GYN residencies with Ryan Program abortion training. Of the 349 residents who responded to the survey, 17.6% reported that the Dobbs decision affected their post-residency plans, and residents who had previously planned to practice in abortion-restrictive states were eight times more likely to report changing their plans than residents who were planning to practice in protected states. In open-ended responses, 90 respondents specifically mentioned the issue of not living in a state with abortion restrictions. This research adds to the growing evidence that abortion restrictions are causing skilled health care providers to leave or avoid abortion-restrictive regions with repercussions for access to the full spectrum of reproductive health care.

5. Pain Management in Abortion Care

Both medication and procedural abortion are associated with pain for most patients. The intensity of pain varies depending on both patient and practice characteristics. In this clinical review, the authors discuss factors that are associated with increased pain, as well as the evidence for the safety and efficacy of various pain control regimens for both medication and procedural abortions. They discuss options to maximize pain control for patients having medication abortions outside a clinical setting, such as prophylactic dosing of NSAIDs. They also review evidence for the use of multimodal pain control during procedural abortion, including the use of IV sedation for facilities able to provide this option. The authors also discuss the safety profiles of various pain management regimens and draw attention to the safety of deep sedation for outpatient procedural abortion without routine endotracheal intubation. This review provides important clinical guidance for providers seeking to maximize pain control for patients having abortions and may be particularly useful in working in conjunction with anesthesia providers.

6. Society of Family Planning Clinical Recommendation: Management of hemorrhage at the time of abortion

While modern abortion methods are extremely safe, with major complications happening at a rate of 0.7 complications per 1,000 abortions, hemorrhage at the time of abortion is the leading cause of abortion-related mortality. In this Society of Family Planning Clinical Recommendation, the authors discuss etiologies and risk factors for hemorrhage and make evidence-based recommendations for reducing hemorrhage mortality, including preoperative assessment and grading of hemorrhage risk, prophylactic use of medications, cervical preparation, and imaging in select patients to reduce hemorrhage risk, as well as a stepwise approach to hemorrhage management. This new guideline provides evidence-based guidance for clinicians seeking to maximally reduce hemorrhage-related abortion morbidity.

7. Society of Family Planning Clinical Recommendation: Medication abortion between 14 0/7 and 27 6/7 weeks of gestation

While abortion after the first trimester may be safely provided with either medication or a procedure, medication abortion after 14 weeks’ gestation may be the preferred modality in regions that lack a provider skilled in procedural abortion or when patients prefer this option. In this Society of Family Planning Clinical Recommendation, the authors review the efficacy and safety of different regimens for medication abortion between 14 and 27 weeks’ gestation. In their discussion of regimen efficacy, the authors highlight the importance of mifepristone prior to misoprostol dosing to reduce abortion duration. In their discussion of safety, the authors mention that retained placenta is the most common complication and review the evidence showing the safety of misoprostol regimens even for patients with a history of C-section. Additional sections discuss the role of pain management, pre-procedure fetal asystole, lactational suppression, and post-abortion contraception. These guidelines can assist providers offering medication abortions at later gestational ages to improve patient experience and safety.

8. Popular Contraception Videos on TikTok: An Assessment of Content Topics

Information from social media has the potential to influence perceptions and opinions about a wide range of topics, including contraception. TikTok, a social media platform providing short-form video content, has an estimated 1.7 billion users, many of whom are young; females aged 10 to 19 are TikTok’s largest user demographic. In this descriptive study using snapshot data collection, the authors collected the 100 most popular English-language videos available on the platform for eight contraception-specific search terms, accruing 700 unique TikTok videos. In terms of content, the authors found that patient experience and logistics of contraception use were the most common topics, each appearing in more than half of all videos. While only 19% of all collected videos were made by health care professionals, these accounted for an outsized percentage of all user views (41%). They also noted that several prolific creators had developed the majority of health care professional videos, with 67% of all health care professional videos ascribed to six creators. The authors urge clinicians to recognize the potential significant influence of social media on young patients’ understanding of contraception, as well as the potential for health care professionals to use this platform to reach broader audiences.

9. Bacterial vaginosis: a review of approaches to treatment and prevention

Bacterial vaginosis (BV) is a common cause of vaginitis among US women, with an estimated prevalence of up to 29-49%. BV symptoms such as abnormal discharge and odor may significantly affect quality of life, and BV is also associated with serious adverse long-term health outcomes such as preterm birth, increased susceptibility to sexually transmitted disease and pelvic inflammatory disease, and post-operative complications such as vaginal cuff infections. While antibiotics can provide a short-term cure for BV, they do not provide a long-term cure with 50-80% of patients treated for BV having a recurrence within a year. In this clinical review, the authors examine whether alternative treatment regimens have been shown to provide improved long-term outcomes for BV. While they discuss there is some promise for probiotic regimens, vaginal pH modulation, and biofilm disruptors, none of these have sufficient clinical evidence for recommendation currently. The authors also discuss home remedies such as dietary supplements, essential oils, and traditional Chinese medicine, but conclude there is even less evidence to recommend or support them. However, lifestyle modifications such as smoking cessation, condom use, hormonal contraception, and avoiding douching have moderate evidence to support their use in patients with recurrent BV. Clinicians caring for patients with recurrent BV can use this review to guide counseling and care plans.

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.
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