Objective

Describe the implementation of a preoperative telemedicine program at a Northern California hospital-based center for abortion procedures requiring cervical preparation.

Study design

We implemented a pilot program using telemedicine for preoperative visits for patients needing cervical preparation prior to an abortion procedure from 12 to 18 weeks. We required ultrasonography for gestational age documentation in addition to placental localization in patients with a prior cesarean delivery. We prescribed misoprostol for cervical preparation for patients undergoing the telemedicine preoperative visit; in-person preoperative visits typically involve placement of osmotic dilators. Secondarily, we surveyed patients who had telemedicine and in-person preoperative visits to compare their preoperative experiences.

Results

Implementation required 8 months of multidisciplinary meetings. From March 2018 through March 2019, we received 200 abortion referrals at 12 to 18 weeks gestation. Of these 200 patients, 119 did not meet telemedicine eligibility criteria, most commonly due to inability to obtain required ultrasonography (n = 89 [75%]). Of the remaining 81 patients, 43 scheduled telemedicine visits of which 41 initiated and 38 (88%) completed the visits. Twenty-one (55%) telemedicine encounters had no or minor technical difficulties. Thirty-one of 34 (91%) telemedicine and 91 of 108 (84%) in-person visit patients expressed high satisfaction with their preoperative appointment (p = 0.4); none reported dissatisfaction. Patients chose the telemedicine visit primarily for convenience and transportation concerns.

Conclusion

A multidisciplinary team is essential for the successful implementation of a preoperative telemedicine program for procedural abortion care. Patients reported high satisfaction and reduced logistical burdens with the telemedicine option.

Implications

Telemedicine preoperative visits for abortion procedures at 12 to 18 weeks gestation may improve access to abortion care, reduce patient burdens, and provide an alternative encounter option which may improve the patient experience.

Objective

To evaluate the proportion of 12-month contraceptive pill, patch, and ring prescriptions before and after an institution-wide change of default electronic medical record facility orders to dispensing 12-month supply.

Study design

This retrospective pre-post study compares outpatient contraception prescriptions from August 10, 2019 through April 9, 2020 obtained from our institutional electronic medical record prescription database. On December 10, 2019, we facilitated a change in the default orders for dispensing self-administered hormonal contraceptives from one-month to 12-months. We evaluated the primary outcome of 12-month supply prescriptions during the four months before and after the change. We also compared 12-month supply prescriptions for pills, patch, and ring by prescriber specialty and location.

Results

The dataset included 4897 distinct evaluable prescriptions for the pill, patch, or ring, with an overall increase in 12-month prescriptions from 260/2437 (10.7%) to 669/2460 (27.2%) after the order change (p < 0.001). Twelve-month pill prescriptions increased from 238/2250 (10.6%) to 607/2250 (27.0%) (p < 0.001), patch prescriptions from 6/40 (15.0%) to 21/44 (47.7%) (p = 0.002), and ring prescriptions from 16/147 (10.9%) to 41/165 (24.8%) (p = 0.001). Twelve-month prescriptions increased after the order change among all provider types at the medical center campus (194/594 [32.7%] to 329/623 [52.8%], p < 0.001). At community clinics, non-obstetrics/gynecology providers increased 12-month prescriptions after the order change (58/1616 [3.6%] to 327/1612 [20.3%], p < 0.001), but obstetrics/gynecology providers did not (8/227 [3.5%] to 13/225 [5.8%], p = 0.27).

Conclusion

Providers more frequently prescribed a 12-month supply of contraceptive pills, patches, and rings after a change in the default dispensing quantity in electronic medical record orders.

Implications

Institution-wide changes to the electronic medical record default facility order settings can increase 12-month supply contraceptive prescriptions. As a 12-month prescription order represents only one step of many in obtaining a 12-month contraception supply, additional research is required to elucidate and remove other potential barriers.

Objectives

To determine progestin-only pill (POP) use at 3 and 6 months postpartum among women who chose POPs at the postpartum visit.

Study design

Secondary data analysis of a prospective observational study with telephone interviews at 3 and 6 months postpartum to assess contraceptive use.

Results

Of 440 women who attended the postpartum visit, 92 (20.9%) chose POPs. Current POP use was 44/84 (52.4%) at 3 months, 33/76 (43.4%) at 6 months, and 32/76 (42.1%) at both 3- and 6-month follow-up assessments.

Conclusion

About half of women who plan POP use at the postpartum visit are not using this method at 3 months after delivery.

Implications

About half of women with a prescription for progestin-only pills will be not using this method at 3 months postpartum; further understanding of continued sexual activity and breastfeeding may clarify pregnancy risk for those not reporting modern contraception use during the postpartum period.

Objective

To describe our experience with office removal of nonpalpable contraceptive implants at our referral center.

Methods

We performed a retrospective cohort study by reviewing the charts of patients referred to our family planning specialty center for nonpalpable or complex contraceptive implant removal from January 2015 through December 2018. We localized nonpalpable implants using high-frequency ultrasonography and skin mapping in radiology, followed by attempted removal in the office using local anesthesia and a modified vasectomy clamp. We abstracted information on demographics, implant location, and outcomes.

Results

Of 61 referrals, 55 patients attended their scheduled appointments. Seven patients had palpable implants; six elected removal. The other 48 patients had ultrasound localization, which identified 47 (98%) of the implants; the remaining patient had successful localization with computed tomography imaging. Nonpalpable implants were suprafascial (n=22), subfascial (n=25) and intrafascial (n=1); four of these patients opted to delay removal. Of 50 attempted office removals, all palpable (n=6), all nonpalpable suprafascial (n=21 [100%, 95% CI 83-100%]), and 19 out of 23 (83%, 95% CI 67-98%) subfascial implants were successful. Three of the four patients with failed subfascial implant office removal had successful operating room removal with a collaborative orthopedic surgeon; the other patient sought removal elsewhere. Transient postprocedure neuropathic complaints were noted in 7 out of 23 (30%, 95% CI 12-49%) subfascial and 1 out of 21 (5%, 95% CI 0-13%) suprafascial removals (P=.048). Nonpalpable implants were more likely to be subfascial in nonobese patients (24/34, 71%) as compared with obese (1/13, 8%) patients (P<.001). Seven (28%) of the 25 subfascially located implants had been inserted during a removal-reinsertion procedure through the same incision.

Conclusion

Most nonpalpable contraceptive implants can be removed in the office by an experienced subspecialty health care provider after ultrasound localization. Some patients may experience transient postprocedure neuropathic pain. Nonpalpable implants in thinner women are more likely to be in a subfascial location.

Objectives

To assess referral center outcomes with removal of difficult or nonpalpable contraceptive implants using high-frequency point-of-care ultrasonography.

Study design

We present a case series examining patients referred to our specialty center from January 2019 through September 2020 for difficult or nonpalpable implant removal.

Results

Of the 54 referrals, 6 had palpable implants and 48 required ultrasonography. We localized 46 (96%) implants in-office, including 13 located subfascially; 2 Implanon implants could not be localized. We successfully completed 50 (96%) of 52 attempted in-office removals, including 12 (92%) subfascial implants.

Conclusion

High-frequency point-of-care ultrasonography can effectively localize nonpalpable contraceptive implants leading to successful in-office removal.

Implications

Specialists can use high-frequency point-of-care ultrasonography to localize nonpalpable implants without formal radiology scans and skilled technologists, optimizing patient time and convenience. However, the probe is expensive, and providers may need to consider this cost in the context of reimbursement for these highly specialized procedures.

Objectives

To evaluate mifepristone impact on osmotic dilator placement and procedural outcomes when given 18 to 24 hours before dilator placement for dilation and evacuation (D&E) at 18 weeks 0 days to 23 weeks 6 days gestation.

Study design

We performed a randomized, double-blind, placebo-controlled trial from April 2019 through February 2021, enrolling participants undergoing osmotic dilator (Dilapan) placement for a planned, next-day D&E. Participants took mifepristone 200 mg or placebo orally 18 to 24 hours before dilator placement. We used a gestational age-based protocol for minimum number of dilators. Our primary outcome was the proportion of participants for whom 2 or more additional dilators could be placed compared to the minimum gestational age-based standard. We secondarily evaluated cervical dilation after dilator removal in the operating room, subjective procedure ease, and complication rates (cervical laceration, uterine perforation, blood transfusion, infection, hospitalization, or extramural delivery).

Results

Of the planned 66 participants, we enrolled 44 (stopped due to coronavirus disease 2019-related obstacles), and 41 (19 mifepristone; 22 placebo) completed the study. We placed 2 or more additional dilators compared to standard in 7 (36.8%) and 3 (13.6%) participants after mifepristone and placebo, respectively (p = 0.14). We measured greater median initial cervical dilation in the mifepristone (3.2 cm[2.6-3.6]) compared to placebo (2.6 cm[2.2-3.0]) group, p = 0.03. Surgeon's perception of procedure being "easy" (8/19[42.1] vs 9/22[40.9], respectively, p = 1.00) and complication rate (3/19[15.8%] vs 3/22[13.6], respectively, p = 1.00) did not differ.

Conclusion

Our underpowered study did not demonstrate a difference in cervical dilator placement, but mifepristone 18 to 24 hours prior to dilators increases cervical dilation without increasing complications.

Implications

Mifepristone 18 to 24 hours prior to cervical dilator placement may be a useful adjunct to cervical dilators based on increased cervical dilation at time of procedure; however, logistical barriers, such as an additional visit, may preclude routine adoption without definite clinical benefit.