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Objective: To compare the effectiveness and safety of dilation and evacuation (D&E) to that of medication abortion at 15-24 weeks in a low-middle income country. Study design: We conducted a retrospective cohort on effectiveness and safety of D&E vs medication abortion at 15-24 weeks in an Ethiopian setting over a year (January 1-December 31, 2023). We looked at success (need for additional procedure) of both abortion procedures and their complication rates. Hemorrhage, infection, uterine perforation/rupture, and cervical tear were the complications we compared between the groups (D&E group vs medication abortion group). P-value less than 0.05 and Adjusted odds ratio (AOR) with 95% CI were used to present results significance. Results: A total of 225 abortion cases (162 medication abortion cases and 63 D&E cases) at gestational age of 15-24 weeks were included in the final analysis. The mean gestational age was 18 ± 2.8 weeks in the D&E group compared to 21 ± 3 weeks in the medication abortion group (p-value < 0.001). The overall procedure effectiveness between the abortion procedures was similar (95.2% vs 96.9% in the D&E group and medication abortion groups, p-value = 0.542). D&E (AOR = 2.92 [95% CI = 0.62-13.69]) was not associated with increased overall complications compared to medication abortion, after controlling for parity, gestational age, and history of prior uterine scar. Conclusion: We found both abortion methods (D&E and medication abortion) are effective with comparable complication rates. Implications: D&E and medication abortion are safe and effective methods of abortion for gestations up to 24 weeks even in a low-middle income country (LMIC) setting; as such, greater resources are needed to ensure to increase availability of D&E in order for women to have a choice in their treatment options.

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OBJECTIVES: This study aimed to compare cervical preparation with transcervical balloon to osmotic dilators for second-trimester procedural abortions. STUDY DESIGN: We performed an unblinded, randomized, noninferiority trial of people undergoing second-trimester procedural abortion at 18 + 0 to 23 + 6 weeks' gestation. We randomized participants to either overnight osmotic dilators (Dilapan-S) or transcervical balloon (Foley). Both groups received overnight mifepristone and preprocedural misoprostol. We powered the study on mean difference in procedure duration, a noninferiority limit of 5 minutes. We compared preprocedure cervical dilation and the need for additional dilation and, using a 100-point visual analog scale, measured physician satisfaction and ease of procedure, and participant pain and satisfaction. RESULTS: We recruited 32 participants at a single academic center. Although procedure time (minutes) was similar (balloon: 22.6 ± 8.9 vs Dilapan-S: 22.4 ± 12.8, p = 0.96), noninferiority was not met (mean difference, 0.2 minutes; 95% CI, -7.8 to 8.2). Cervical dilation >2 cm was more likely after Dilapan-S (100% vs 62.5%, p = 0.02). Placement was well tolerated with similar time (minutes) for insertion (balloon: 4.8 ± 1.0, Dilapan-S: 5.1 ± 2.3, p = 0.64) and maximum pain (median) with insertion (balloon 39 [5-78], Dilapan-S: 39 [0-100], p = 0.92). Pain immediately postinsertion was higher for Dilapan-S (33 [0-100] vs 18 [0-50], p = 0.046) and similar for maximum pain overnight, participant satisfaction, and likelihood to recommend. Complications were minor and similar between groups (p = 0.60). CONCLUSION: While significantly more people with transcervical balloon required mechanical dilation, the difference in operative time was clinically negligible. The transcervical balloon was well tolerated and acceptable by participants. IMPLICATIONS: Clinicians experienced in mechanical dilation may consider a transcervical balloon as a lower-cost tool for second-trimester abortion cervical preparation. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov: NCT05099991.

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OBJECTIVES: To determine how obstetrician-gynecologists categorize pregnancy-ending interventions in the setting of lethal fetal anomalies. STUDY DESIGN: We conducted a sequential explanatory mixed-methods study of U.S. obstetrician-gynecologists from May to July 2021. We distributed a cross-sectional online survey via email and social media and completed qualitative telephone interviews with a nested group of participants. We assessed institutional classification as induced abortion versus indicated delivery for six scenarios of ending a pregnancy with lethal anomalies after 24 weeks, comparing classification using McNemar chi-square tests with Benjamini-Hochberg correction for multiple comparisons with a false discovery rate of 0.05. We performed the thematic analysis of qualitative data and then performed a mixed-methods analysis. RESULTS: We included 205 respondents; most were female (84.4%), had provided abortion care (80.2%), and were general OB/GYNs (59.3%), with broad representation across pre-Dobbs state and institutional abortion policies. Twenty-one qualitative participants had similar characteristics to the whole sample. All scenarios were classified as induced abortion by the majority of respondents, ranging from 53.2% for 32-week induction for anencephaly, to 82.9% for feticidal injection with 24-week induction for anencephaly. Mixed-methods analysis revealed the relevance of gestational age (later interventions less likely to be considered induced abortion) and procedure method and setting (dilation and evacuation, feticidal injection, and freestanding facility all increasing classification as induced abortion). CONCLUSIONS: There is wide variation in the classification of pregnancy-ending interventions for lethal fetal anomalies, even among trained obstetrician-gynecologists. Method, timing, and location of ending a nonviable pregnancy influence classification, though the perinatal outcome is unchanged. IMPLICATIONS: The classification of pregnancy-ending interventions for lethal fetal anomalies after 24 weeks as indicated delivery versus induced abortion is reflective of sociopolitical regulatory factors as opposed to medical science. The regulatory requirement for classification negatively impacts access to care, especially in environments where induced abortion is legally restricted.

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Objective: Document the clinical outcomes of an outpatient medical management with procedural evacuation backup procedure for abortions between 18 weeks zero days to 23 weeks six days gestation. Study design: We conducted a retrospective medical records review of adult patients who received mifepristone and repeated misoprostol for second trimester abortion with procedural evacuation backup at an Arizona clinic between October 2017 and November 2021. We extracted patient demographics; pregnancy and medical history; and preoperative, intraoperative, and postoperative data. We assessed abortion outcomes, including procedure timing, mode of completion (medication alone or medications and procedural evacuation), and safety. Results: All 359 patients had a complete abortion with 63.5% of patients completing with medication alone and 36.5% with procedural evacuation backup. The median time from first dose of misoprostol to fetal expulsion was six hours, among those who completed the abortion with medications alone. Of those who received procedural evacuation as backup, the median time for procedural evacuation was 10 minutes. The vast majority of patients (99.4%) did not have any adverse events. Two safety incidents (0.6%) occurred, a broad right ligament tear and a uterine rupture. Conclusion: Patients in one outpatient setting safely and effectively received medical management of second trimester abortion with procedural evacuation backup, and two thirds completed with medications alone. Implications: Outpatient settings may consider medical management of abortion between 18 and 24 weeks with procedural evacuation back-up as a safe, effective, and manageable second trimester abortion option. Additional research is needed on patient experience and satisfaction.

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Many pregnant people learn of fetal anomalies in the second trimester and subsequently present to prenatal genetic counselors (PGCs) for counseling, including but not limited to a nuanced discussion about whether to continue or terminate pregnancy. In those who choose to terminate, the decision between dilation and evacuation (D&E) or induction is often one of patient preference and as such, is heavily influenced by the quality of counseling received. PGCs are expertly trained to provide values-based counseling, yet little is known about their termination counseling practices, referral practice patterns, and perceived responsibilities in caring for this group of pregnant people. To gain this knowledge, we surveyed a national sample of PGCs in early 2022 and received 70 completed responses. The survey contained open- and closed-ended questions. Data were analyzed using descriptive statistics, and free response data were analyzed using inductive content analysis. Eighty percent (n = 56) of respondents reported that <50% of their patients had previously received termination options counseling. Most strikingly, 15% of respondents provided termination counseling that was beyond their self-identified comfort level. Scenario-based questions assessed respondents' counseling practice patterns in seven real-world situations, presented in order of decreasing severity for the fetus. Respondents were 50% less likely to provide termination options counseling to patients between the most lethal to the least lethal proposed fetal anomaly. The scenario-based analysis revealed two distinct termination counseling approaches: (1) all options counseling with an explicit discussion of options to continue or terminate and (2) discretionary options counseling focused on identifying patient preferences to guide counseling and not explicitly stating all available options. This study highlights the need to ensure PGCs feel well-trained to discuss the general features of second trimester pregnancy termination and, if unable to do so, to practice in systems with timely referral to providers well-versed in the counseling about all methods of termination.

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OBJECTIVES: This study aimed to compare effectiveness and safety of cervical preparation with osmotic dilators plus same-day misoprostol or overnight mifepristone prior to dilation and evacuation (D&E). STUDY DESIGN: We conducted a retrospective cohort analysis of 664 patients initiating abortion between 18 and 22 weeks at an ambulatory health center. We abstracted medical record data from two consecutive 12-month periods in 2017 to 2019. All patients received overnight dilators plus: 600 mcg buccal misoprostol 90 minutes before D&E (period 1); 200 mg oral mifepristone at time of dilators (period 2). Our primary outcome was procedure time. We report frequency of patients experiencing any acute complication, defined as unplanned procedure (i.e., reaspiration, cervical laceration repair, uterine balloon tamponade) or hospital transfer and bleeding complications. RESULTS: We observed higher mean procedure time in the mifepristone group (9.7 ± 5.3 minutes vs 7.9 ± 4.4, p = 0.004). After adjusting for race, ethnicity, insurance, body mass index, parity, prior cesarean, prior uterine surgery, gestational age, provider, trainee participation, and long-acting reversible contraception initiation, the difference remained statistically significant (relative change 1.09, 95% CI 1.01, 1.17) but failed to reach our threshold for clinical significance. The use of additional misoprostol was more common in the mifepristone group, but the use of an additional set of dilators was not different between groups. Acute complications occurred at a frequency of 4.1% in misoprostol group and 4.3% in mifepristone group (p = 0.90). CONCLUSIONS: We found procedure time to be longer with adjunctive mifepristone compared to misoprostol; however, this difference is unlikely to be clinically meaningful. Furthermore, the frequency of acute complications was similar between groups. IMPLICATIONS: Overnight mifepristone at the time of cervical dilator placement is a safe and effective alternative to adjuvant same-day misoprostol for cervical preparation prior to D&E and may offer benefits for clinic flow and patient experience.

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OBJECTIVES: Patients with intrauterine fetal demise (IUFD) are at higher risk of complications when undergoing dilation and evacuation (D&E) compared to patients undergoing abortion for other indications. We aimed to compare baseline characteristics and describe outcomes, including frequencies of complications such as disseminated intravascular coagulation (DIC) and hemorrhage, in patients undergoing D&E for IUFD vs induced abortion, with a goal of identifying associated risk factors for complications. STUDY DESIGN: We conducted a retrospective matched cohort study of patients undergoing nonemergent D&Es for singleton ≥14-0/7-week IUFD January 1, 2019 to May 31, 2021, matched with two patients undergoing induced second-trimester D&Es by cesarean delivery history, patient age, and gestational age (GA). We collected demographics, history, GA, coagulation studies, quantitative blood loss (QBL), and complications. We calculated descriptive statistics and tested for association using chi-square, Fisher's exact, t, and Wilcoxon's rank sum tests. RESULTS: Of 1390 procedures, 64 patients with IUFD met inclusion criteria and were matched with 128 patients undergoing induced D&E. Eight (12.5%) patients with IUFD and six (4.7%) undergoing induced D&E had hemorrhage (odds ratio [OR] = 2.90, 95% confidence interval [0.96, 8.77]). Six (9.4%) patients with IUFD and none undergoing induced D&E had DIC (OR = 28.56 [1.58, 515.38]). Median QBL was 75.0 mL (50, 162.5) for patients with IUFD vs 110.0 mL (50, 200) for those undergoing induced D&E (p = 0.083). Twelve (18.8%) patients with IUFD vs seven (5.5%) undergoing induced D&E received at least one intervention due to bleeding complications (p = 0.004). CONCLUSIONS: We found a higher DIC frequency but no significant difference in hemorrhage or QBL in IUFD D&E compared to induced abortion. Our IUFD D&E complication frequency is higher than those previously published. IMPLICATIONS: Our results affirm current standards of care for D&E in patients with IUFD. Large referral centers may have higher proportions of complications compared to other sites.

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Uterine incarceration is a rare pregnancy complication that occurs when the uterine fundus becomes trapped beneath the sacral promontory. We present a case of incarceration in a patient seeking dilation and evacuation and a discussion of strategies for uterine reduction and cervical preparation.

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OBJECTIVES: To explore how US obstetrician-gynecologists (OB/GYNs) classify periviable pregnancy-ending interventions for maternal life endangerment. STUDY DESIGN: From May to July 2021, we performed an explanatory sequential mixed methods study of US OB/GYNs, recruited through social media and professional listservs. We administered a cross-sectional survey requesting institutional classification of labor induction or surgical evacuation of a 22-week pregnancy affected by intrauterine infection, using chi-square tests and logistic regression to compare determinations by physician and institutional factors. We then conducted semistructured interviews in a diverse nested sample to explore decision-making, merging quantitative and qualitative data in a mixed methods analysis. RESULTS: We received 209 completed survey responses, with 101 (48.3%) current abortion providers and 48 (20.1%) never-providers, and completed 21 qualitative interviews. Fewer than half of respondents reported that pregnancy-ending intervention for 22-week intrauterine infection would be classified as induced abortion at their institution (induction: 21.1%, dilation & evacuation: 42.6%, p < 0.001). In addition to procedure method, decision-making factors for classification as abortion included personal experience with abortion (with more experienced participants more likely to identify care as abortion) and state and institutional abortion regulations ("I have to call it a medical [induction]… I'm not allowed to use the word abortion"). CONCLUSIONS: Most OB/GYNs do not classify periviable pregnancy-ending interventions for life-threatening maternal complications as induced abortion, especially when physicians and institutions have less abortion expertise. Differential classification of pregnancy-ending care may lead to undercounting of later abortion procedures, masking the impact of abortion restrictions. IMPLICATIONS: Under unclear legal definitions, legislative interference, and administrative overreach, subjectivity in classification creates inconsistency in care for pregnancy complications. Failure to classify life-saving care as abortion contributes to stigma and facilitates restrictions, with increased danger and less autonomy for pregnant people.

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OBJECTIVES: To assess the analgesic efficacy of preoperative gabapentin among patients undergoing dilation and evacuation (D&E) with moderate sedation. STUDY DESIGN: We conducted a randomized, controlled, double-blind trial among patients undergoing same-day D&E at 14 to 19 weeks gestation under moderate sedation. We randomized participants 1:1 to gabapentin 600 mg or placebo after cervical preparation at least 1 hour prior to D&E. We assessed pain using a 100-mm visual analog scale before, during, and after the procedure. The primary outcome was postoperative recall of maximum procedural pain with a 13-mm a priori threshold for clinical significance. We standardized initial fentanyl and midazolam dosing. We assessed satisfaction with pain control, nausea, and vomiting via Likert scales and anxiety using a validated instrument. RESULTS: We enrolled 126 participants and randomized 61 to gabapentin and 65 to placebo, with study medication administered a mean of 211 (SD 64) minutes preoperatively. Recall of maximum pain was 41 mm for gabapentin and 49 mm for placebo (p = 0.24). Gabapentin resulted in reduced pain during uterine aspiration (56 vs 71 mm, p= 0.003) compared to placebo, but not for any other time points. The gabapentin group had higher satisfaction (78% vs 65% very or somewhat satisfied, p= 0.01). Median fentanyl dose was lower in the gabapentin group (75 vs 100 mcg, p = 0.005). Midazolam dose, nausea, vomiting, and anxiety did not differ between groups. No serious adverse events occurred in the gabapentin group. Sedation reversal was not required. CONCLUSIONS: The addition of gabapentin to moderate sedation during D&E did not result in lower maximum recalled procedural pain. Gabapentin resulted in reduced intra-operative pain during uterine aspiration and increased satisfaction with pain control. IMPLICATIONS: Gabapentin reduces intraoperative pain and improves satisfaction with pain management when administered prior to second-trimester surgical abortion and may be considered as an adjunct to intravenous sedation. Moderate sedation may impair assessment and recall of pain. Additional research is needed to identify the most effective pain management regimens for D&E.

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OBJECTIVES: To assess if quantitative blood loss (QBL) with dilation and evacuation (D&E) procedures correlated with clinically relevant outcomes or hemorrhage. STUDY DESIGN: We used a de-identified database to review D&E procedures performed at UC Davis Health from April 2019 through March 2020. Surgeons determined QBL during procedures and estimated blood loss, when excessive, during post-procedure recovery. We extracted patient demographic and procedure-related information. We defined clinically relevant bleeding as cases with bleeding-related interventions within 24 hours post-procedure including use of ≥2 uterotonics, tranexamic acid administration, cervical injury requiring repair, uterine balloon tamponade, blood transfusion, uterine artery embolization, hospitalization, or return to operating room; the latter 5 criteria defined hemorrhage. We used χ2 test for trend to evaluate bleeding outcomes. RESULTS: We evaluated 431 procedures with a mean gestational age of 19 weeks and 3 days. Clinically relevant bleeding outcomes occurred in 6/319 (2%), 15/97 (15%) and 7/12 (58%) patients with total blood loss <250mL, 250-500mL and >500mL, respectively (p<0.0001); 11 had bleeding related to cervical injuries. Hemorrhage occurred in 0, 4/97 (4%) and 5/12 (42%) patients, respectively (p<0.0001). Patients with relevant bleeding outcomes had QBLs ranging from 150-1800mL (median QBL 312.5mL, interquartile range [IQR] 250-550mL) while those without clinically relevant bleeding ranged from 10-900mL (median QBL 150mL, IQR 75-200mL). CONCLUSION: Most patients (75%) with clinically relevant bleeding outcomes had QBL ≤500mL. Although higher QBL correlates with clinical interventions, the need for significant interventions rather than a single blood loss amount should be used to define hemorrhage with D&E procedures. IMPLICATIONS: Clinical hemorrhage is best defined by the necessary clinical interventions required to manage bleeding rather than any quantified amount of blood loss.

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OBJECTIVE: To evaluate clinical differences in the safety of dilation and evacuation (D&E) and induction of labor (IOL) for the treatment of intrauterine fetal demise (IUFD) between 14 and 24 weeks gestation. STUDY DESIGNS: A retrospective chart review was conducted at a single institution comparing rates of major and minor complications between patients who undergo D&E and those that undergo IOL in the treatment of IUFD between 14 and 24 weeks gestation. Demographic and medical variables were stratified by management method and analyzed using chi-squared and t-tests where appropriate. RESULTS: Patients who underwent IOL were of a more advanced gestational age and more likely to be uninsured. Patients who underwent D&E were more likely to be privately insured. Hospital time for an IOL was significantly longer than for D&E. Composite rates of complication did not differ significantly between management groups. Patients treated with D&E were more likely to require uterine aspiration. CONCLUSIONS: D&E and IOL are equally safe methods for the management of IUFD between 14 and 24 weeks gestation. Both options should be made available to patients who experience this rare pregnancy outcome.

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OBJECTIVE: To describe the rate of vomiting from oral doxycycline 200 mg given the night before second trimester dilation and evacuation (D&E), proportion of anesthesia modalities, and anesthetic complications. STUDY DESIGN: We conducted a single-institution retrospective cohort study of patients presenting for second trimester D&E (14-0/7 to 23-6/7 weeks gestation) July 1, 2019-June30, 2020 following their scheduled preoperative visit as identified by billing codes. We recorded vomiting within 30 minutes of ingestion, anesthetic modality, and anesthetic complications. We tested for associations using chi-square or Fisher's exact test for categorical variables and Wilcoxon-rank sum for non-normal numeric variables. RESULTS: We reviewed 702 charts, of which 461 (66%) met inclusion criteria and 420 (60%) took doxycycline as prescribed. Of those who took doxycycline as prescribed, 30 (7.14%) reported vomiting within 30 minutes of ingestion. Nulliparity, primigravida and age less than 30 were significantly associated with vomiting (p = 0.005, p < 0.001 and p = 0.03, respectively), but gestational age (p = 0.53), BMI (p = 0.93), and gastrointestinal conditions (p > 0.99) were not. Only gravidity (p < 0.001) and parity (p = 0.01) remained significant in each of their respective multivariate models. None of the 10 patients who received general endotracheal tube anesthesia (2.4%) had vomited from doxycycline preoperatively. We observed 5 (1.2%) anesthetic complications (postoperative nausea or vomiting, anaphylaxis, and aspiration) that occurred only in those without vomiting. CONCLUSIONS: Vomiting rates following doxycycline were lower than those previously published. We found no significant association between doxycycline-associated vomiting and increased need for general endotracheal tube anesthesia or anesthetic complications; however, our study is underpowered to draw further conclusions. IMPLICATIONS: The findings of this study are consistent with guidelines indicating deep sedation as an effective anesthetic modality with low complication rates. Nulliparous patients may benefit from administration of an antiemetic prior to doxycycline prophylaxis, but routine antiemetic use may not be necessary.

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Dilation and evacuation (D&E) is the recommended surgical procedure for uterine evacuation in the second trimester. Despite its established safety record, it is not routinely available in most countries around the world. In this paper, we describe the multi-phase capacity-building project we undertook to introduce D&E in Brazil. First, we invited a highly motivated obstetrician-gynecologist and abortion provider to complete an observership at an established D&E site in the United States. We then organized a month-long clinical training for two experienced gynecologists in Brazil, followed by ongoing remote mentorship. Almost all patients we approached during the training opted for D&E, and all expressed satisfaction with their experience. Despite the restrictive legal setting and prevailing abortion stigma in Brazil, our training was well-received, and we did not experience any overt resistance from hospital staff. We learned that obtaining institutional support is essential; and that presenting scientific evidence during dedicated didactic times was an important strategy to obtain buy-in from other local healthcare providers. An important challenge we encountered was low case volume given the restrictive legal setting. We addressed this by partnering with nearby hospitals and non-profit organizations for patient referrals. We also rescheduled, adapted and optimized this project for implementation in the midst of the COVID-19 pandemic. Despite the challenges we faced, this project led to the successful introduction of D&E up to 16-18 weeks at two sites in Brazil. In the future, we plan additional training to increase capacity for D&E at more advanced gestational ages.

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OBJECTIVE: To estimate the rate of requiring more than one 300-mcg Rh D immune globulin dose for fetomaternal hemorrhage (FMH) at the time of second-trimester dilation and evacuation (D + E). STUDY DESIGN: We performed a retrospective cohort analysis of patients at greater than 20 weeks' gestation who underwent D + E, had Rh D-negative blood type, and received FMH quantification testing. RESULTS: Of 25 eligible patients, 24 had negative quantification of FMH; one had positive quantification that did not meet the clinical threshold for additional dosing. CONCLUSIONS: The absolute risk of requiring additional Rh D immune globulin after D+E for pregnancies greater than 20 weeks' gestation was 0%.

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We describe a complication from same-day cervical preparation with simultaneous use of Aquacryl hydrogel osmotic dilator, laminaria and misoprostol vaginally for a same-day dilation and evacuation procedure at 19 weeks' gestation. The laminaria fragmented and embedded in the cervix at the time of procedure. Removal was unsuccessful in clinic and the patient was discharged on one week of antibiotics. The patient returned after the administration of misoprostol vaginally and the surgeon found the fragment in the vagina. We cannot conclude if the fragment was expelled with misoprostol use or prior to its administration.

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This case demonstrates a successful dilation and evacuation (D&E) at 21 weeks gestation for a patient with abdominal cerclage without initial advanced dilation. We followed a 2-day protocol with placement of 5 laminaria and mifepristone for cervical preparation without complication.

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OBJECTIVE: The aim of the study was to evaluate pain following overnight osmotic cervical dilator placement for second trimester dilation and evacuation (D&E). METHODS: A retrospective cohort study surveyed pain and quantified prescription opioid use among 100 women who underwent overnight osmotic cervical dilator placement for D&E. Participants were given opioid and non-steroidal anti-inflammatory (NSAID) prescriptions and were asked to rate their level of pain on a Likert scale (1-10). Demographic and medical information was abstracted from electronic medical records. Bivariate analyses of demographic and clinical characteristics by pain score and opioid use were conducted. Multivariate linear regression analyses were performed for pain score. A multivariate logistic regression model was fitted for factors associated with opioid use. RESULTS: Gestational age ranged from 14 to 23 weeks (average 19 ± 3 weeks). The mean score of worst pain experienced was 5.3 out of 10. Participants reported 3.4 h of moderate pain (4-6 out of 10) and 1.0 h of severe pain (7-10 out of 10); 54% of women took at least one opioid (mean 2.8 ± 1.5). Multivariate analysis showed that higher pain was associated with younger age (p = .0363) and no prior vaginal delivery (p = .0296). The number of osmotic cervical dilators was associated with pain in the bivariate analysis (r = 0.216, p = .0311) but was not significant in the multivariate analysis (p = .0634). An increasing number of cervical dilators (p = .0323) and a higher pain score (p = .004) were associated with opioid use. CONCLUSION: Most participants with overnight cervical dilators for D&E experienced at least moderate pain and used opioid pain medication in addition to NSAIDs when available. A shared decision-making model may be appropriate for determining which patients may benefit from opioids.

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OBJECTIVE: Document the effectiveness and safety of Foley balloon catheter and misoprostol use for cervical preparation before a same-day dilation and evacuation (D&E). STUDY DESIGN: We conducted a retrospective medical records review of adult patients with viable pregnancies at 18 weeks 0 days to 21 weeks 6 days gestation who received a same-day D&E at an Alabama clinic using a 30-cc Foley balloon catheter and misoprostol for cervical preparation from January 2016 through December 2017. Patients received misoprostol 800 mcg buccally at the time of Foley placement and then every 4 hours until the physician deemed that dilation/effacement was adequate to proceed with a D&E. We extracted patient demographics, pregnancy and medical history, and preoperative, intraoperative, and postoperative data. We primarily evaluated effectiveness (D&E completion within one procedure day). Our secondary outcomes included safety, time between misoprostol and procedure start time, length of D&E, recovery time, and number of doses of misoprostol provided. RESULTS: Two hundred and ninety patient charts met our review criteria - all of whom had a complete abortion in one day. Only one safety incident, a cervical laceration, occurred (0.3% of all procedures). The median time between Foley placement and first misoprostol dose and the procedure start was 7.2 hours (2.9-12.6 hours; interquartile range [IQR] 6.2-8.4 hours); median procedure length was 12 minutes (2-40 minutes; IQR 10-15 minutes); and median recovery time 14 minutes (4-89 minutes; IQR 14-16 minutes). Most patients needed two doses of misoprostol (n = 258, 89%), and 11 (4%) needed three doses; 21 (7%) patients needed one dose of misoprostol. CONCLUSION: Patients in the mid-second trimester can effectively and safely undergo cervical preparation with a Foley balloon catheter and misoprostol to facilitate completion of same-day D&E. IMPLICATIONS: Foley balloon catheter use with misoprostol for cervical preparation for second-trimester abortion (the Robinson Foley protocol) is effective and safe and can be completed in one day when used by an experienced physician.

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BACKGROUND: Conjoined twins are a rare clinical event occurring in about 1 per 250,000 live births. Though the prognosis of conjoined twins is generally low, there is limited evidence as to the optimal method of pregnancy termination, particularly in cases of advanced gestational age. We report a successful dilation and evacuation (D&E) done for conjoined twins at 22 weeks of gestation. CASE PRESENTATION: A 20-year-old primigravid woman was diagnosed with a conjoined, thoraco-omphalopagus twin pregnancy after undergoing a detailed two-dimensional (2D) fetal ultrasound anatomic scanning. Assessment and counseling were done by a multidisciplinary team. The team discussed the prognosis and options of management with the patient. The patient opted for termination of pregnancy. Different options of termination were discussed and the patient consented for D&E, with the possibility of reverting to hysterotomy in case intraoperative difficulty was encountered. A 2-day cervical preparation followed by D&E was done under spinal anesthesia and ultrasound guidance. CONCLUSION: In this patient, D&E was done successfully without complications. Adequate cervical preparation, pain control, and ultrasound guidance during the procedure are critical for optimal outcomes. A literature review of methods of pregnancy termination for conjoined twins in the second trimester revealed 75% delivered vaginally through medical induction while 18% underwent cesarean section. Only one other report described successful D&E for conjoined twins after 20 weeks. D&E can be safely performed for carefully selected cases of conjoined twins beyond 20 weeks' gestations avoiding the need for induction or hysterotomy.

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