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    Use of Medications To Decrease Bleeding During Surgical Abortion: A Survey of Abortion Providers' Practices in The United States

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    Dea Fathia
    This survey studied the use of medications by US abortion providers to decrease bleeding during surgical abortions. The majority of respondents used prophylactic medications, most commonly misoprostol, oxytocin, methylergonovine, or vasopressin. Providers' choice and timing of medications varied based on gestational age. For treating excessive bleeding, misoprostol and methylergonovine were preferred first-line treatments by most providers. The study provides information on abortion providers' current practices around using medications before and after surgical abortions to reduce bleeding.

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    Use of Medications To Decrease Bleeding During Surgical Abortion: A Survey of Abortion Providers' Practices in The United States

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    Dea Fathia
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    This survey studied the use of medications by US abortion providers to decrease bleeding during surgical abortions. The majority of respondents used prophylactic medications, most commonly misoprostol, oxytocin, methylergonovine, or vasopressin. Providers' choice and timing of medications varied based on gestational age. For treating excessive bleeding, misoprostol and methylergonovine were preferred first-line treatments by most providers. The study provides information on abortion providers' current practices around using medications before and after surgical abortions to reduce bleeding.

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    This survey studied the use of medications by US abortion providers to decrease bleeding during surgical abortions. The majority of respondents used prophylactic medications, most commonly misoprostol, oxytocin, methylergonovine, or vasopressin. Providers' choice and timing of medications varied based on gestational age. For treating excessive bleeding, misoprostol and methylergonovine were preferred first-line treatments by most providers. The study provides information on abortion providers' current practices around using medications before and after surgical abortions to reduce bleeding.

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    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    13 views13 pages

    Use of Medications To Decrease Bleeding During Surgical Abortion: A Survey of Abortion Providers' Practices in The United States

    Uploaded by

    Dea Fathia
    This survey studied the use of medications by US abortion providers to decrease bleeding during surgical abortions. The majority of respondents used prophylactic medications, most commonly misoprostol, oxytocin, methylergonovine, or vasopressin. Providers' choice and timing of medications varied based on gestational age. For treating excessive bleeding, misoprostol and methylergonovine were preferred first-line treatments by most providers. The study provides information on abortion providers' current practices around using medications before and after surgical abortions to reduce bleeding.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 13

    Use of medications to decrease bleeding

    during surgical abortion:


    a survey of abortion providers' practices
    in the United States
    Introduction
    • Abortion is one of the most common surgical procedures in the
    United States, with nearly one million procedures performed in
    2014. Although complications from abortion happen infrequently,
    one of the more commonly occurring is hemorrhage, reported in
    1% to 6% of procedures.

    • The prevalence range may be due to inconsistent definitions of


    post-abortion hemorrhage; blood loss volume (250-500 mL),
    treatment of bleeding, and the need for transfusion have all been
    used to define blood loss. Medications commonly used to decrease
    bleeding include methylergonovine maleate, misoprostol, oxytocin,
    carboprost tromethamine, and vasopressin. Some providers
    prophylactically use medications during surgical abortion to
    decrease the risk of hemorrhage, while others only administer
    these medications to treat excessive bleeding.
    • Although the Society of Family Planning (SFP) presents an algorithm
    for management of excess bleeding during abortion, the actual
    practice of abortion providers throughout the country is neither
    standardized nor well described.

    • The National Abortion Federation (NAF) conducts periodic surveys


    of abortion provider practices; however, they do not ask in-depth
    questions about use of medications to prevent bleeding. With
    minimal available evidence on how to best use medications to
    decrease bleeding during surgical abortion, future randomized
    controlled trials could evaluate the medications that providers
    commonly use to provide evidence-based guidelines for abortion
    care. The aim of this study is to document the medications most
    commonly used to decrease bleeding during surgical abortion by a
    population of United States providers.
    Methods
    Subscribers consisted of clinical and research experts on abortion and contraception.
    We excluded subscribers who were not abortion providers.
    We asked providers about their :
    (1) use of prophylactic medications to decrease bleeding during surgical abortion
    (2) use of medications to treat excessive bleeding during surgical abortion
    (3) preferred medications, timing, dosage, and route.
    (4) basic demographic and clinical practice information.

    Respondents could choose from pre-coded responses but were encouraged to provide
    additional details if necessary. Three weeks after distributing the survey, we sent a
    reminder email to all listserv subscribers and provided a final reminder in person at a
    national academic abortion provider conference. The University of Hawaii Human
    Studies Program Institutional Review Board approved this study.
    We used R software version 3.0.3 to perform
    data analysis. We investigated differences in
    provider characteristics and typical practices
    between those who routinely used prophylactic
    medications to decrease bleeding during
    abortion and those who did not using chi-square
    and Fisher’s exact tests.
    Result
    3.1 Prophylactic medications used by abortion providers
    Result
    For uterotonic medications, one provider (1%) started at less
    than 13 weeks’ gestation, 11 (9%) at 13 to 16 weeks’, 30 (25%)
    at 16 to 19 weeks’, nine (7%) at 19 to 22 weeks’, and four (3%)
    at 22 to 24 weeks’ gestation. For vasopressin, 35 providers
    (29%) initiated use at less than 13 weeks’ gestation, 45 (37%)
    at 13 to 16 weeks’, 18 (15%) at 16 to 19 weeks’, and one (1%)
    at 19 to 22 weeks’ gestation. Providers reported use of
    medication combinations such as oxytocin and
    methylergonovine above 16 to 18 weeks’ gestation or
    oxytocin and misoprostol above 13 weeks’ gestation. A few
    respondents stated that they used misoprostol for cervical
    preparation and assumed that this had some prophylactic
    uterotonic effects.
    • Ninety-seven prophylactic medication users provided information
    about their preferred dosing regimens. Respondents used
    vasopressin most commonly as an intracervical plus paracervical
    injection at doses of 4 to 10 units (most commonly 4 or 5 units),
    and diluted it in 10- to 30-mL (most often 20 mL) of saline or
    lidocaine. One provider diluted vasopressin in 500 mL of fluids to
    administer intravenously. The majority used methylergonovine
    intramuscularly. Respondents gave oxytocin at 10 to 40 units (most
    commonly 20 units), primarily intravenously. One provider used it
    paracervically. Providers administered misoprostol buccally,
    vaginally, and rectally via doses of 400- to 1000-mcg (most
    frequently 400- or 800-mcg). Finally, one provider reported
    injecting carboprost intracervically during the paracervical block.
    • Among providers who did not routinely use prophylactic medications
    during surgical abortions, 83% (35/42) cited “poor medical evidence to
    support use.” Providers also reported concern for side effects (10/42,
    24%), cost (9/42, 21%), lack of a physiological mechanism (8/42, 19%),
    difficulty obtaining medications (3/42, 7%), and other (8/42, 19%) as
    reasons for not using prophylactic medications. Sixteen percent (7/42) of
    these providers reported that they previously used prophylactic
    medications but have changed their practice because of a shortage of
    medications (namely methylergonovine) or a change in practice site. Fifty-
    six percent (23/42) of providers who do not routinely use prophylactic
    medications would do so in certain situations including coagulopathy
    (n=13, 57%), abnormal placentation (n=12, 52%), history of bleeding
    disorder (n=9, 39%), history of hemorrhage (n=9, 39%), grandmultiparity
    (n=8, 35%), anticoagulant use (n=8, 35%), anemia (n=7, 30%), multiple
    gestation (n=5, 22%), polyhydramnios (n=4, 17%), fetal demise (n=4, 17%),
    prior Cesarean delivery (n=3, 13%), uterine fibroids (n=2, 9%), and uterine
    anomaly (n=1, 4%).
    3.2 Medications used to treat excessive bleeding by second-trimester abortion providers

    The majority of our respondents (88%) provided second-trimester surgical abortions and gave
    information on their preferences for treatments for bleeding (Table 3). Overall, Providers preferred
    methylergonovine or misoprostol as a first- (91%) or second-line (76%) treatment. Fourteen percent
    (20/148) of providers selected carboprost as a second-line treatment, in contrast to 1% who used it as
    first-line treatment. Providers gave additional information about the routes and doses they preferred to
    use as treatments for bleeding. Of the 110 providers who selected misoprostol, 94% (n=103) prefer 800
    or 1000 mcg per rectum (n=95, 86%). Among the 25 who selected oxytocin as a treatment, 88% (n=22)
    used it intravenously. We found no clear consensus on the dosage of oxytocin administered; 36% used
    20 units (n=9), 24% used 40 units (n=6), and 20% used 10 (n=5) or 30 units (n=5). Providers using
    vasopressin as a treatment (n=3) indicated they preferred a dose of 2 units intracervically. A few
    providers stated that they inject methylergonovine or vasopressin transcervically into the myometrium
    to treat heavy bleeding. Some second-trimester providers commented that access and cost of
    medications affected their practice. For example, one provider previously used dilute IV vasopressin but
    switched to oxytocin due to the cost of vasopressin.

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