1. Rh D Immune Globulin Administration After Abortion or Pregnancy Loss at Less Than 12 Weeks of Gestation
Rh immunoglobulin (RhIg) has historically been recommended for all pregnant patients with an Rh-negative blood type to prevent Rh alloimmunization of a future pregnancy whenever there is the possibility of exposure to fetal blood, including during miscarriage and abortion. However, recent research and population-level evidence has increasingly suggested that the risk of Rh sensitization from pregnancies less than 12 weeks gestation is extremely low. In this updated ACOG Clinical Practice Update, the authors review the existing evidence and officially recommend foregoing routine Rh testing and RhIg administration for patients undergoing abortion or experiencing pregnancy loss at less than 12 0/7 weeks of gestation, though discuss that they may be considered on an individual basis in shared-decision making with a patient. This recommendation contributes to the growing number of professional institutions recommending foregoing Rh testing and RhIg in the first 12 weeks of pregnancy, including the Society of Family Planning, World Health Organization, and others.
2. Comparison of medication abortion outcomes at less than and greater than six weeks gestation
Medication abortion using mifepristone and misoprostol is safe and effective and is now the most common abortion method used in the US. While medication abortion is thought to be effective at very early gestational durations, there is comparatively less data on its use in patients less than six weeks’ gestation. Given that more states are enacting bans limiting abortion care after six weeks, it is important to understand how medication abortion works for these patients. In this retrospective cohort study, the authors identified 142 patients seeking medication abortion at less than or equal to 42 days’ gestation and compared them with patients between 43 and 56 days’ gestation. In their analysis, they found that there was not a significant difference between the success of medication abortion (94% versus 97%) and unscheduled ED visits or phone calls. However, patients in the earlier group were more likely to have unscheduled office visits (13% vs 6%) and were also more likely to report that their successful medication abortion did not cause bleeding or cramping worse than their regular periods; they were also more likely to report no pregnancy symptoms before presenting for care. The authors discuss that these findings can help with anticipatory guidance for patients undergoing medication abortion before six weeks’ gestation, as their symptoms may differ.
3. Success of medication abortion with mifepristone followed by two doses of misoprostol in very early pregnancy
Many patients present for abortion care at six weeks’ gestational duration or earlier. Some evidence suggests that medication abortion may be less effective at this earlier stage than later. In this retrospective cohort analysis, the authors analyzed whether adding a second dose of misoprostol would improve the efficacy of medication abortion for early pregnancies. They identified more than 900 patients who presented for abortion care with very early pregnancies, defined as either a pregnancy of unknown location or gestational sac only (no yolk sac or fetal pole) seen on ultrasound, and compared the outcomes of those who received one versus two doses of misoprostol after mifepristone. In their analysis, they found that there was no significant difference in medication abortion success between the groups, with 87.9% success in the single-dose group and 85.5% in the double-dose group. This study contributes to growing evidence that medication abortion is slightly less effective for abortion in very early pregnancy compared to increased gestational durations but that increasing doses of misoprostol does not appear to mitigate this. Providers can use this data to counsel patients presenting for abortion care, especially emphasizing the importance of follow-up to ensure successful medication abortion.
4. Society of Family Planning Clinical Recommendation: Induction of fetal asystole before abortion Jointly developed with the Society for Maternal-Fetal Medicine
Inducing fetal asystole before either procedural or medication abortion may be an important consideration in abortion care, especially for pregnancies close to or after the point of viability. While evidence has not clearly shown that inducing asystole increases the safety of procedural abortion or improves outcomes with medication abortion, induction of fetal asystole prevents the rare but serious occurrence of unanticipated fetal expulsion with cardiorespiratory activity. Providers and institutions with different clinical contexts and capacities may incorporate this step into their abortion care in various ways. In this joint clinical recommendation, the authors discuss the safety and efficacy of various pharmaceutical forms of inducing fetal asystole, including intraamniotic/intrafetal digoxin, intrathoracic/intracardiac/intrafunic potassium chloride (KCl), and intracardiac/intrafetal/intrafunic lidocaine. The authors discuss scenarios where one approach may be preferred, such as the use of intracardiac KCl or lidocaine when asystole must be rapidly achieved. However, they emphasize that the agent and approach chosen for fetal asystole will depend on availability, time frame, and clinicians’ technical abilities, and all three agents are acceptable. This guideline can be used by providers considering fetal asystole to design their treatment plan and to appropriately counsel patients.
5. Body Mass Index Changes Among Adolescents and Young Adults Using the Etonogestrel Contraceptive Implant
The etonogestrel contraceptive implant (Nexplanon) is a highly effective form of long-acting reversible contraception that can be safely used by almost all patient populations, including adolescents and young adults. While initial clinical trials of the implant did not show a clear association with weight gain, perceived weight gain is a common recent for discontinuation among younger patients. In this retrospective longitudinal cohort study, the authors identified more than 20,000 patients between 13 and 21 years old who initiated either the implant, depot medroxyprogesterone acetate (DMPA), or a weight-neutral contraceptive (IUDs, combined hormonal contraception, or progestin-only pills) or no contraceptive, and followed their BMI over time. They found that there were no differences in mean BMI by group at baseline but that the mean BMI trajectory of the implant group was similar to that of the DMPA group and significantly higher than the control group at both 6 and 9 months. Patients who initiated the implant or DMPA had a mean BMI change of approximately one BMI unit over a three-year period. However, the authors note that changes in BMI weight categories (underweight, normal weight, overweight, or obese) were rare for individual patients, so the clinical implications of these changes are less clear. These findings can potentially help providers counsel patients about weight changes when considering contraception options, especially for patients who are concerned about weight gain as a potential side effect.
6. Exploring adolescent-facing US clinicians’ perceptions of their contraceptive counseling and use of shared decision-making: A qualitative study
Barriers to contraceptive access exist throughout the US, and they may be especially elevated for adolescents and young adults who face worries about privacy, stigma, and autonomy. Contraception counseling in the US has shifted from a tiered, efficacy-oriented model to a focus on shared decision-making (SDM), in which the provider and patient decide together based on the patient’s priorities and the available evidence. This qualitative study was performed to assess the perspectives and counseling strategies of reproductive health care providers who specifically care for adolescents, aiming to understand the role of SDM in this setting. The 15 study subjects were asked to reflect on how they discuss choice, options, and decision-making with their patients. The authors found that numerous non-patient-centered approaches were used, including efficacy-focused counseling and decisions based on clinical availability or sociodemographic factors. These results highlight a need for additional training and education on contraception counseling for providers who care for adolescent patients, particularly regarding their own personal biases.
7. Adolescents and Young Adults' Sources of Contraceptive Information
Access to accurate information about contraception is a crucial component of autonomy in reproductive health care, and this is especially true for adolescents and young adults who may face difficulty in finding private, trustworthy sources. By understanding where this cohort finds information, providers and other caretakers can better support their decision-making processes. For this study, researchers analyzed survey data from more than 1,000 participants ages 15-29 who were assigned female at birth. The majority of participants preferred clinicians as their sources of information about birth control, though they reported not always being able to gain access to them. These results highlight a potential gap in access for this age group, suggesting that virtual or online clinician engagement may be one way to support the reproductive autonomy of adolescents and young adults. Interested readers can find more details here, as this study used data from Power to Decide’s annual #ThxBirthControl survey, which provides essential information on young people’s decisions in reproductive health care.
8. Selection of LARC methods by emergency contraception clients: A prospective observational study
The copper intrauterine device (IUD) is well established in its efficacy as emergency contraception (EC), and recent data also supports the levonorgestrel (LNG) IUD for this purpose. While data regarding the etonogestrel implant (Nexplanon) as EC is lacking, it can be placed at an EC visit if taken together with oral LNG EC. The authors of this study sought to understand which long-acting reversible contraception (LARC) device patients would choose among these three options at a visit for EC. Of more than two thousand patients seeking EC during the study period, 305 (14.5%) requested LARC. While the authors initially imagined that patients would want to avoid the dual tasks of having a new implant placed and taking a levonorgestrel pill, this was not borne out by the results. Within the LARC-seeking cohort, the majority preferred the implant plus oral LNG as compared to either copper or LNG IUD, despite the fact that there is more limited efficacy information on this method. This study reveals a need for more research focused on the implant for EC, along with qualitative explorations of patient preferences for LARC in this setting.
9. Local anaesthesia for pain control in surgical abortion before 14 weeks of pregnancy: a systematic review
The majority of abortions take place before 14 weeks gestational duration, both procedural and medication, and pain control is frequently the chief concern for patients. Pain during procedural abortion is complex and multifactorial, often stemming from both physical and psychosocial factors. Although multiple methods of treating and addressing pain do exist in the setting of first-trimester procedural abortion, this systematic review focuses on local anesthesia. The authors found that a 20mL 1% lidocaine paracervical block did significantly reduce pain during both cervical dilation and uterine aspiration and that no significant differences were noted when adding buffer or a topical agent or waiting to start the procedure. Additionally, two injection sites seem to work as well as four, and a 1.5 cm depth of injection appears to be sufficient (vs. 3 cm). This information can be used to inform strategies around lidocaine administration for first-trimester procedural abortion. Evidence was insufficient to allow the authors to compare the paracervical block with topical lidocaine or an intracervical block. More studies are needed to understand the differences between these methods better.
