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Objective: To retrospectively investigate cesarean scar pregnancy (CSP) patients who received systemic methotrexate (MTX) and to clarify the criteria for administering systemic MTX to CSP patients., Materials and Methods: Fifteen CSP patients who were initially treated with systemic MTX (50 mg/m 2 /week) were included. Nine patients, who needed a uterine artery embolization (UAE) or a laparotomy, including a transabdominal hysterectomy (TAH), were defined as the unsuccessful MTX group. Six patients who did not require UAE or a laparotomy were defined as the successful MTX group. Furthermore, the hCG cut-off value and the GS cut-off size at the time of CSP diagnosis, which differentiated successful and unsuccessful patients, were defined. MTX success rates were investigated by combining the hCG and gestational sac (GS) size cut-off values., Results: The hCG cut-off value was 17757.0 mIU/mL, and the GS cut-off size was 10.4 mm. In patients with hCG values less than 17757.0 mIU/mL, the MTX success rate was 75.0%. Fewer patients needed UAE or a laparotomy compared to patients with hCG values higher than 17757.0 mIU/mL (P = 0.007). In patients with a GS size less than 10.4 mm, the MTX success rate was 80.0%. Fewer patients among them needed UAE or a laparotomy compared to those among patients with a GS size greater than 10.4 mm (P = 0.089). In patients with hCG values and GS sizes lower than the cut-off values, the MTX success rate was 80.0%. Fewer patients among them needed UAE or a laparotomy compared to those among patients with hCG values and/or GS sizes higher than the cut-off values, respectively (P = 0.010)., Conclusion: Patients with hCG values less than 17757.0 mIU/mL and GS sizes less than 10.4 mm may have a greater chance of successful systemic MTX treatment when it is used as the first line of treatment for CSP., Competing Interests: Declaration of competing interest None., (Copyright © 2021. Published by Elsevier B.V.)

This meta-analysis was performed to compare the efficacy and safety of dilatation and curettage (D&C) (simply D&C or combined with other treatments) and lesion resection for cesarean scar pregnancy (CSP). A search of English and Chinese databases from 2010 to 2019 was conducted. Thirty one studies were retrieved including sixteen random controlled and fifteen case controlled trials. Compared with abdominal resection surgery(ARS) and vaginal resection surgery(VRS), uterine artery embolization(UAE)+D&C has no obvious difference in curative effect and safety (UAE + D&C versus ARS: Cure rate(CR): P = 0.076, time for menstruation recovery/β-HCG normalization: P = 0.545/0.949,Blood loss: P = 0.005, adverse event: P = 0.420; versus VRS: CR: P = 0.085, time for menstruation recovery/β-HCG normalization: P < 0.001/P = 0.031,Blood loss: P = 0.902, adverse event: P = 0.249). UAE + D&C associated with lower blood loss and less postoperative complication than laparoscopic resection surgery(LRS), but LRS take more advantages in terms of the curative effect (CR: P = 0.047, time for menstruation recovery/β-HCG normalization: P = 0.352/0.103). The efficacy and safety of VRS are better than D&C, methotrexate (MTX) + D&C (D&C versus VRS: CR: P < 0.001, time for β-HCG normalization: P = 0.363,blood loss: P < 0.001, adverse event: P = 0.046; MTX + D&C versus VRS: CR: P < 0.001, time for menstruation recovery/β-HCG normalization: P < 0.001/P = 0.005, blood loss: P < 0.001, adverse event: P < 0.001). Lesion resection had advantages in shorter time for menstrual recovery/β-HCG normalization and less adverse events, lower failure rate over the administration of D&C treatments. In detail, the curative effect of UAE + D&C is similar to ARS and VRS, but inferior to LRS, while the safety of UAE + D&C is better than LRS. The efficacy and safety of simply D&C and MTX + D&C are not as good as VRS., Competing Interests: Declaration of competing interest All Authors declare that they have no conflict of interest., (Copyright © 2021. Published by Elsevier B.V.)

Objective: The reproductive outcomes of ovarian pregnancy are currently unknown. Therefore, the objective of our study was to report the pregnancy outcomes of women with laparoscopically treated ovarian pregnancy., Materials and Methods: In this retrospective case analysis, unpublished cases of ovarian pregnancy between 2009 and 2016 were reviewed. Women were followed up for 3 years to obtain subsequent pregnancy data., Results: A total of 21 women who intended to become pregnant were included in this study. Predisposing risk factors for ovarian pregnancy including previous pelvic surgery (23.81%), presentation of pelvic endometriosis (23.81%), and prior intrauterine device insertion (9.52%) were identified. The major symptom at presentation was abdominal pain (85.71%), and no preoperative sonographic diagnosis of ovarian pregnancy was identified. Laparoscopic wedge resection was performed in most women (90.48%). During the 3-year follow-up period, spontaneous intrauterine pregnancy was observed in 13 women (61.90%), 2 women (9.52%) became pregnant through artificial insemination treatment, and 6 women are not able to get pregnant (28.57%). None of the women experienced recurrent ectopic pregnancy., Conclusion: The postoperative pregnancy outcomes of women with ovarian pregnancy were encouraging. In this study, the spontaneous intrauterine pregnancy rate was favorable, and no cases of recurrent ectopic pregnancy were reported., Competing Interests: Declaration of competing interest The authors declare there are no conflict of interests., (Copyright © 2021. Published by Elsevier B.V.)

Some complications of pregnancy that occur in the second trimester, such as preeclampsia, bleeding placenta previa, and preterm premature rupture of membranes, require delivery to avoid maternal morbidity and mortality. When these situations occur before fetal viability, pregnancy termination, either by induction of labor or dilation and evacuation, can be lifesaving. To optimize maternal health in these situations, Maternal Fetal Medicine providers should be trained to provide all needed medical services, including termination. Currently, only the minority of Maternal Fetal Medicine providers are skilled in dilation and evacuation. Training programs should focus on ways to facilitate training in second trimester dilation and evacuation to improve care access and quality when these medically necessary procedures are needed for women in whom a healthy pregnancy is no longer an option., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Several states attempted to deem abortions nonessential during the COVID-19 pandemic, leaving some women with difficult choices.

Objectives: To analyze the effectiveness and outcome of conservative treatment in cases of abnormally located intrauterine pregnancies (cervical and cesarean scar). Study design: A retrospective analysis was performed of 30 pregnant women hospitalized due to abnormally located intrauterine pregnancies. The analyzed group comprised 24 pregnant women with abnormally located pregnancies. The patients were divided into two groups: the first group consisted of patients treated systemically with methotrexate, while the second of those treated locally by administration of methotrexate (MTX) and/or potassium chloride (KCl) by gestational sac puncture. Results: The analyzed group comprised 24 pregnant women with abnormally located pregnancies. Eight patients were diagnosed with cervical pregnancy (CP) and 16 patients were diagnosed with cesarean scar pregnancy (CSP). Six patients were excluded from the study: two with spontaneous abortions, two heterotopic pregnancies, and two cornual pregnancies. Twelve analyzed patients underwent MTX systemic administration (five patients with CP, seven with CSP). In five patients, systemic treatment was ineffective; they were qualified for additional local therapy with gestational sac (GS) puncture and MTX or KCl administration to the sac and additional administration of MTX to the trophoblast area. In second group of 12 patients (three CP, nine CSP), local treatment (GS puncture with MTX or MTX + KCl) was used as the first line treatment. One patient underwent combined treatment (local + systemic). Conclusions: Conservative treatment should be the gold standard procedure in abnormally located intrauterine pregnancies. It is noticeable that MTX / KCl is more effective in a direct administration to the GS. In four cases, systemic MTX did not produce the desired effects. In these cases, the treatment was assisted by local administration of MTX or KCl, resulting in the termination of an abnormally located pregnancy.

Multifetal gestation is often complicated by the development of preeclampsia. In some twin gestations, preeclampsia develops in association with restricted fetal growth of only one fetus. Instead of termination of the entire pregnancy, we investigated an alternative approach to the management of such pregnancies that might allow unharmed survival of the normal twin. We present a case of preeclampsia in twin discordance with severe fetal growth restriction at 25 weeks of gestation. Preeclampsia was linked to a lethal condition in one twin and was treated with selective feticide in an effort to reverse preeclampsia. Inasmuch as the fetal prognosis was extremely poor for the abnormal fetus, selective feticide was a reasonable therapeutic option. Maternal symptoms resolved, allowing continuation of the pregnancy for 4 weeks before delivery of the healthy fetus. We maintain that selective termination induced a decrease in the release of substances involved in the physiopathology of preeclampsia, which allowed the continuation of the pregnancy with close follow-up. This report highlights the link between placental pathology and the disease process of preeclampsia and further supports selective termination as a reasonable management strategy in carefully selected cases of discordant twins., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Objective: To examine the association between fetal death and risk of hemorrhage and disseminated intravascular coagulation (DIC) among women undergoing dilation and evacuation (D&E) procedures., Methods: We conducted a retrospective cohort study of all D&Es at one academic abortion clinic in San Francisco between 2009 and 2013. We abstracted data on fetal death status, demographic characteristics, and complications including hemorrhage and DIC. We examined the risk of hemorrhage and DIC among women with fetal death compared with those without. We conducted unadjusted and adjusted analyses for the outcomes of hemorrhage, DIC, and any complication., Results: Among 92 cases of D&E for fetal death and 4,428 cases of D&E for other reasons, hemorrhage occurred in 10% and 7%, respectively (P=.28), and DIC occurred in 2.0% and 0.2% of the fetal death and nonfetal death cohorts (P<.001). In adjusted analysis, fetal death was associated with 2.9 times higher odds of hemorrhage (95% CI 1.4-6.0). In an unadjusted analysis, fetal death was associated with 12.3 times higher odds of DIC (95% CI 2.6-58.6) and 3.0 times higher odds of any complication (95% CI 1.6-5.9)., Conclusion: Women undergoing D&E for fetal death are far more likely to experience DIC and hemorrhage than are women without fetal death, yet the absolute risk is low (2%). Although D&E providers should be prepared for DIC and hemorrhage, we do not recommend any specific preoperative preparation because the vast majority of D&E abortions for fetal death are uncomplicated.

Splenic pregnancy is a rare form of ectopic pregnancy, with only 21 cases reported in PubMed since 1970. Here we report the case of a healthy 28-year-old woman with splenic pregnancy who complained of menolipsis lasting 56 days and left upper quadrant pain lasting 30 days. The level of β-human chorionic gonadotropin in serum was 8399 mIU/mL, and transvaginal ultrasonography showed the uterine cavity to be empty without signs of adnexal mass. Subsequent abdominal ultrasonography detected a hyperechoic mass below the spleen containing an anechoic mass measuring 2.6 × 1.2 × 1.6 cm. Laparoscopy detected a gestational mass measuring 6.0 × 4.0 × 3.0 cm on the lower border of the spleen. Pregnancy tissues and a clot were removed under laparoscopic guidance, and the spleen was preserved. Our case suggests that removal of chorionic villi tissue, although not a standard procedure, may be effective for treating splenic pregnancy., (© 2019 Japan Society of Obstetrics and Gynecology.)

Background: This study aims to evaluate the curative effect and complications in cesarean scar pregnancy (CSP) patients treated with a transvaginal injection of absolute ethanol (AE) around the gestation sac (GS) under ultrasound guidance., Methods: This retrospective clinical investigation analyzed 26 CSP patients treated at the Affiliated Hospital of Guilin Medical University in Guilin, Guangxi, China, between January 1, 2018 and January 30, 2019. Outcomes and complications were analyzed following treatment with AE., Results: Out of the entire group, 20 patients were successfully treated with a single AE injection, while the remaining six patients required two or three repeat injections. In 21 patients, the serum beta-human chorionic gonadotropin (β-hCG) level was reduced to > 50% 1 day after a single AE injection; in 19 patients, the serum β-hCG level was reduced to > 80% 4 days after a single AE injection. In all patients, the average time for serum β-hCG to reduce to normal levels (< 3.0 mIU/mL) was 36.50 ± 12.54 days. The overall cure rate of CSP by AE injection was 100%. Average length of hospitalization was 6.73 ± 3.66 days, with Patient 2 having the longest hospitalization at 17 days, and Patient 3 the shortest at 2 days. No adverse effects on hematopoietic, hepatic or renal function were observed in the short term., Conclusion: The study demonstrated that transvaginal injection of AE around the gestation sac under ultrasound guidance had good clinical effects, fewer complications, and merit as a novel treatment for CSP. However, larger multi-center trials are needed to confirm the safety and effectiveness of this treatment.

Background: Adeno-associated viruses (AAVs) have been found in human blood cells, cervical biopsies, and epithelial cell brushings, endometrium, and abortion material, which suggest their possible roles in the induction of miscarriage., Objective: In this case control study, the presence of AAV DNA in placental tissue of spontaneous and therapeutic abortions was compared., Method: Placenta samples were evaluated for AAV DNA by hemi-nested PCR in miscarriages occurring in the first 24 weeks of pregnancy from therapeutic and spontaneous abortions., Results: Eighty-one therapeutic abortions (control group) and 83 spontaneous abortions (case group) were evaluated. Sixty-two (38.2%) of 164 abortions were AAV positive, including 35 (21.6%) spontaneous abortions and 27 (16.6%) therapeutic abortions., Conclusion: There was no statistically significant difference between the presence of the AAV genome in spontaneous and therapeutic abortions. This observation was consistent with other studies in this area.

Objectives: For early miscarriage (pregnancy loss ≤ 12 weeks of gestation), two types of therapeutic treatment are offered (pharmacotherapy and curettage of the uterine cavity) depending on the presence and severity of clinical symptoms as well as patient choice. Our study aimed to assess the diagnostic value of the results of histopathological examinations of miscarriage products in relation to the administered treatments., Material and Methods: 850 medical records from patients diagnosed with missed miscarriage or empty gestational sac were analyzed retrospectively. Patients underwent surgical treatment or pharmacotherapy. Inefficacy of pharmacotherapy resulted in subsequent curettage. The results of histopathology were evaluated for their diagnostic value and classified: subgroup 1 - high value specimen (the studied specimen included fetal tissues, and villi), and subgroup 2 - no-diagnosis (the studied specimen included maternal tissues, autolyzed tissues, blood clots). Data were compared with chi-squared test. Differences was considered significant at p < 0.05., Results: 1128 histopathological test results were analyzed; 569 (50.4%) were obtained during pharmacotherapy and 559 (49.6%) after curettage; out of the latter 497 after the initial pharmacotherapy and 62 after surgery. In the pharmacotherapy group, high value specimens comprised 231 cases (40.59%) while no diagnosis was obtained in 338 cases (59.4%). Considering specimens obtained in the course curettage, high value specimens were found in 364 cases (65.1%) while results that did not allow a diagnosis to be made were found in 195 cases (34.9%)., Conclusions: Tissue specimens of high diagnostic value are obtained significantly more often during surgical treatment of miscarriage than during pharmacotherapy.

Objectives: The mortality of pregnant women with idiopathic pulmonary arterial hypertension (PAH) is very high. There are limited data on the management of idiopathic PAH during pregnancy. The authors aimed to examine systematically the characteristics of parturient women with idiopathic PAH, to explore the adverse effects of idiopathic PAH on pregnancy outcomes, and to report the multidisciplinary perioperative management strategy from the largest comprehensive cardiac hospital in China., Design: Observational case series study., Setting: Tertiary referral acute care hospital in Beijing, China., Participants: The cases of 17 consecutive pregnant idiopathic PAH patients undergoing abortion or parturition at Anzhen Hospital were reviewed retrospectively., Interventions: Preoperative characteristics, anesthesia method, intensive care management, PAH-specific therapy, and maternal and neonatal outcomes were analyzed in this case series study., Measures and Main Results: Maternal and neonatal outcomes were the main measures. The mean ages of the 17 parturient women with idiopathic PAH were 28.3 ± 5.4 years, and the mean systolic pulmonary arterial pressure was 97.9 ± 18.6 mmHg. Fifteen patients (88.2%) received PAH-specific therapy before delivery, including sildenafil, iloprost, and treprostinil. All except 1 parturient received epidural anesthesia for surgery due to an emergency Caesarean section. Three patients experienced pulmonary hypertension crisis that necessitated conversion to general anesthesia. Ten parturients underwent Caesarean delivery at a median gestational age of 31 weeks. Three patients developed acute pulmonary hypertensive crisis intraoperatively. Two patients underwent cardiopulmonary resuscitation and extracorporeal membrane oxygenation support. The maternal mortality was 17.6% (3/17). Of the 10 delivered neonates, 9 (90.0%) survived., Conclusions: The maternal mortality of the idiopathic PAH parturient was high in this case series from China. The authors applied epidural anesthesia, early management with multidisciplinary approaches, PAH-specific therapy, avoidance of oxytocin, and timely delivery or pregnancy termination to improve maternal and neonatal outcomes., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Less than 100 cases of gestational gigantomastia have been described in literature. The aetiology and risk factors are not well-established. Various treatments have been used with some consensus. We present the case of a 47-year-old female who presented to us with bilateral gigantomastia in her 16th week of gestation. She had massively enlarged breasts which were very painful. Relevant laboratory investigations were normal. An incisional biopsy done prior to, and two trucut samples at presentation to us, showed normal breast tissue proliferation. In the absence of adequate pain control, it was decided to electively terminate the pregnancy and give a trial of tamoxifen. She made a rapid recovery following termination without requiring the use of tamoxifen.

Background: Abortion, spontaneous or induced, is a common complication of pregnancy and exploration of available and safe regimens for medical abortion in developing countries seems crucial., Aims: The present study was aimed to assess the effect of letrozole in combination with misoprostol in women eligible for legal therapeutic abortion with gestational age ≤14weeks., Materials and Methods: This clinical randomized trial was conducted on 78 women who were candidate of medical abortion and eligible for legal abortion with gestational age ≤14 weeks that were randomly divided into two groups of case and controls. Case group received daily oral dose of 10mg letrozole for three days followed by vaginal misoprostol. In control group the patients received only vaginal misoprostol. The rate of complete abortion, induction-of-abortion time, and side-effects were assessed., Results: Complete abortion was observed in 30 patients (76.9%) in case group and 9 (23.1%) cases were failed. In control group there was 16 (41.03%) complete abortions and 23 (58.97%) cases were failed to abort. Patients with gestational age of between 6 and 10 weeks did not show significant difference in both groups (P=0.134). Regarding pregnancy remnants there were significant differences between two groups (P=0.034). The time form admission to discharge in case groups were significantly shorter than those in control group (P=0.001). The indication for curettage in case group was significantly less than control group (P=0.001)., Conclusion: A 3-day course of letrozole (10mg/daily) followed by misoprostol was associated with a higher complete abortion and lower curettage rates and reduction in time from admission to discharge in women with gestational age ≤14 weeks compared to misoprostol alone., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

BACKGROUND Troponin I is the gold standard for the diagnosis of adult acute coronary syndrome. Although it is known that a hypoxic fetus may produce cTnI, fetal cTnI passage in maternal blood has never been documented. CASE REPORT We report a case where the rise of cTnI in the blood of a pregnant woman was not related to maternal heart disease. Instead, it might be suggestive of a fetal cardiac origin, as there was a severe placental insufficiency with a fetal intrauterine growth restriction. CONCLUSIONS This study suggests that the rise of cTnI in maternal blood in a cardiovascular healthy pregnant woman might have a fetal origin. After having excluded any maternal causes, cTnI elevation could be explained with the transfer of fetal cTnI through an injured placenta.

Uterine artery embolization (UAE)-assisted induction of labor is an alternative method of managing pregnant women with complete placenta previa (CPP). Sepsis secondary to UAE, although rare, is a serious complication. We herein present a case of severe sepsis following UAE-assisted termination of a pregnancy at 27 gestational weeks in a woman with CPP. The woman developed a high-grade fever and elevated inflammatory indices following UAE. She did not recover until the infected tissue was removed by emergency cesarean section. This case suggests that the increasing use of UAE for termination of pregnancy in women with CPP requires awareness regarding the possibility of serious sepsis associated with this procedure.

Objective: This study sought to compare contraception provided to patients after medication and surgical abortion., Study Design: Women who underwent first trimester induced abortion at a university-based urban clinic between May 2009 and May 2014 were identified. Medical records were reviewed to determine the method of contraception provided by the clinic to patients after medication and surgical abortion. Postabortal contraception was defined as any contraception administered or prescribed from our health system within 4 weeks of surgical abortion or mifepristone administration., Results: We reviewed 824 women who were 9 weeks gestational age or less and able to choose between medication and surgical termination of pregnancy. Overall, 587 (71.1%) had a surgical abortion and 237 (28.9%) had a medication abortion. Women who had surgical abortions were more likely to initiate long-acting reversible contraception (41.9% vs. 23.2%; p < .0001) and more likely to be provided with any type of contraception overall (83% vs. 64.6%; p < .0001). The overall follow-up rate after medication abortion was 71.7%., Conclusions: Women who had surgical abortions had a greater odds of receiving long-acting reversible contraception than those who had medication abortions. Surgical abortion patients were also more likely to be provided contraception overall. Further prospective research is needed to determine the reasons for this difference and to ensure that all patients obtain the contraception that they desire., (Copyright © 2017 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Objectives: To report our experience with the management of Caesarean scar pregnancy (CSP) in the first trimester and to develop a unique treatment algorithm allowing physicians to customize their management based on clinical patient characteristics., Methods: A retrospective review of 12 patients diagnosed with CSP between December 2012 and June 2016 was conducted in a tertiary care hospital in Toronto. All patients were diagnosed with CSP by transvaginal ultrasound using radiologic criteria. Patients were initially treated with an ultrasound-guided embryocidal injection when fetal heart activity was present. Next, patients underwent medical management with systemic multidose methotrexate (MTX) or surgical management using a laparoscopic or transcervical approach depending on CSP characteristics., Results: The mean age at diagnosis was 35.6 years. The median number of previous CSs was one. The mean serum human chorionic gonadotropin level was 59 938 IU/L. The mean GA at presentation was 8+1 weeks. Two-thirds of patients received medical management with systemic multidose methotrexate. Of these, 50% required additional surgical treatment for the resolution of their CSP. One-third of patients underwent primary surgical treatment, resulting in complete resolution of CSP with no complications. Given the improved outcomes of surgical management in our series, we suggest a treatment algorithm that tailors the surgical approach, either laparoscopic or transcervical, to the characteristics of the CSP., Conclusion: This constitutes the largest case series of CSP in Canada. Based on our results, CSP can be safely and effectively managed using the suggested surgical algorithm, which accounts for individual patient characteristics., (Copyright © 2017 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Parturients may present with evidence of acute heart failure or respiratory distress during the peripartum period. This case report documents utilization of "stand-by" extracorporeal membrane oxygenation (ECMO) for a 40-year-old woman with a history of severe left ventricular dysfunction who presented for elective dilation and evacuation of triplets at 20 weeks' gestation. The patient's medical history was significant for hypertension, diabetes mellitus, methamphetamine use (acute/chronic), and cardiac-respiratory arrest before her previous emergent cesarean delivery. The patient underwent general anesthesia with the placement of peripheral venous and arterial cannulas for "stand-by" ECMO. The patient remained stable throughout the procedure, and "stand-by" ECMO was not initiated; the patient was discharged 5 days' postprocedure. The use of "stand-by" ECMO in the parturient with severe cardiopulmonary dysfunction is still in its infancy. Centers managing populations of both high-risk parturients and nonparturients may consider development of algorithms for implementation and utilization of ECMO.

To evaluate the efficency and safety of laparoscopic surgery in the treatment of interstitial heterotopic pregnancy (IHP) after IVF-ET, five patients with interstitial heterotopic pregnancy after IVF-ET treated by laparoscopy in our hospital from Jan. 2012 to Jan. 2015 were retrospectively analyzed. All operations were finished laparoscopically without any major complications and they successfully delivered. The results suggest that laparosccpic surgery is feasible and safe for IHP to maintain the trauterine pregnancy, and it can diagnose and treat IHP at early stage, which cause mininmal injuries and less disturbance to trauterine pregnancy and ensure rapid recovery.

Objective: To evaluate the effect of insertion of etonogestrel implants with mifepristone compared with after the abortion on the risks of medical abortion failure and repeat pregnancy over the subsequent 6 months., Methods: In a randomized trial, we assigned patients undergoing medical abortion to receive etonogestrel implants either with the mifepristone (Quickstart group) or after the abortion (Afterstart group). We followed them for 7 months to ascertain abortion outcome, pregnancies, and contraception use., Results: Between September 2013 and August 2014, we enrolled 236 participants in the Quickstart group and 240 in the Afterstart group. To examine abortion failure, we conducted a noninferiority analysis from which we excluded nine participants who had missing outcome data and four with specified protocol violations. Of the rest, 9 of 229 (3.9%) and 9 of 234 (3.8%) in the Quickstart and Afterstart groups, respectively, had surgery to complete the abortion; the difference of 0.08% (90% confidence interval -3.1% to 3.3%) excluded our prestipulated noninferiority margin of 5 percentage points. Among participants with pregnancy follow-up through 6 months, 1 of 213 (0.5%) and 3 of 208 (1.4%) in the Quickstart and Afterstart groups, respectively, became pregnant within that time; 6-month pregnancy rates did not differ significantly by group (exact log-rank test, P=.28). At enrollment, significantly more participants in the Quickstart group than in the Afterstart group were satisfied with their group assignments (187/236 [79%] compared with 129/240 [54%], respectively; P<.001)., Conclusion: Insertion of etonogestrel implants with mifepristone did not appreciably increase medical abortion failure risk and it enhanced patient satisfaction, but we found no evidence that it decreased repeat pregnancy rates., Clinical Trial Registration: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01902485.

Objectives: This study aimed to explore maternal-fetal medicine specialists' experiences of conducting feticide in late termination of pregnancy., Methods: Participants were recruited via email. Purposeful sampling resulted in ten maternal-fetal specialists. Semistructured interviews were used to examine their experiences of conducting feticide. Interviews occurred across four English National Health Service hospitals. Interpretative phenomenological analysis was used., Results: An ongoing doctor-patient relationship when conducting feticide facilitated participants' self-image as clinicians rather than technicians. Coping involved rationalisation, with feticide viewed as 'part of the job'. Supportive team relationships helped keep emotional expression within control. Participants were not distressed if they felt, through relationship-based decision-making, that the feticide aligned with their values and legal interpretation. To avoid negative judgements, they disclosed selectively, only telling trusted individuals that they conducted feticides., Conclusions: Participants experienced conducting feticides as difficult but necessary, eliciting pride from the skills involved. Some noted management of personal distress. Optimal conditions were involvement in the process from the initial decision-making and team support. Providing feticides was deemed as potentially stigmatising, with selective disclosure employed. Training in managing feticides and guidance on providing optimal service conditions may decrease selectivity of disclosures and enhance staff well-being and the quality of feticide provisions. © 2015 John Wiley & Sons, Ltd., (© 2015 John Wiley & Sons, Ltd.)

Objectives: To determine the factors influencing the abortion interval (AI) for medical termination of second-trimester pregnancy using misoprostol., Materials and Methods: All patients who were admitted for second-trimester pregnancy termination between January 2008 and August 2013 were reviewed. Those who received either 200 μg or 400 μg of priming vaginal misoprostol, followed by 200 μg of misoprostol orally at 6-hour intervals were enrolled., Results: In a total of 101 patients, delivery occurred within 24 hours of commencement in 62 patients (61%) and within 48 hours in 84 patients (83%), and the median AI was 16.5 hours. One patient (1%) failed to deliver. The remaining 100 fetuses were delivered successfully, and the median AI was 16.3 hours. Higher parity [hazard ratio (HR) = 1.28, p = 0.04], the presence of intrauterine fetal demise (HR = 2.66, p = 0.003), and the presence of premature preterm rupture of membranes (HR = 4.51, p = 0.003) were associated with shorter AI. Additionally, all women with premature preterm rupture of membranes delivered successfully within 12 hours; higher parity (odds ratio = 2.12, p = 0.01) and lower fetal birth body weight (odds ratio = 0.992, p = 0.01) were associated with successful delivery within 12 hours. There was no significant difference in AI in the groups that received different doses of priming vaginal misoprostol (200 μg vs. 400 μg)., Conclusion: Higher parity, intrauterine fetal demise, and preterm premature rupture of membranes were associated with shorter AI. The regimen of 200 μg oral misoprostol at 6-hour intervals following a 200 μg or 400 μg priming vaginal dose is feasible and efficacious for second trimester pregnancy termination., (Copyright © 2015. Published by Elsevier B.V.)

Cardiomyopathies are a small percentage of heart disease in pregnant women, but usually cause severe complications. It is not know the exact incidence of cardiomyopathy associated with pregnancy in Europe. In these patients, there is a higher probability of death due to changes in hemodynamic, metabolic and hemostatic that occur in pregnancy. Pregnant mortality is 2.4% vs. 0.007%--in the normal population. The most common cause of severe maternal complications is peripartum cardiomyopathy (PPCM). In dilated cardiomyopathy (DCM) and restrictive (RCM) is usually observed significant clinical deterioration during pregnancy. On the other hand, in patients with hypertrophic cardiomyopathy (HCM), pregnancy and childbirth are often associated with a low risk of complications. There is a greater risk in women presenting symptoms before and on pregnancy and in women with large inrtaventricular and subaortic pressure gradient. There are only a few case reports of pregnancy in patients with rare storage diseases and infiltrative phenotype of hypertrophic cardiomyopathy. For these patients the pregnancy is contraindicated. In patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) is sometimes the severity of arrhythmia in the third trimester of pregnancy, and childbirth (natural or cesarean section) is usually safe. Remember to informing women with various cardiomyopathies both the risks of pregnancy and about the possibility of transferring the disease to offspring. Contraception should be advised in many cases.