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Psychosocial stress has been identified as a potential risk factor for preterm birth. However, an association has not been found consistently, and a consensus on the extent to which stress and preterm birth are linked is still lacking. A literature search was performed with a combination of keywords and MeSH terms to detect studies of psychosocial stress and preterm birth. Studies were included in the review if psychosocial stress was measured with a standardized, validated instrument and if the outcomes included either preterm birth or low birthweight. Within the 138 studies that met inclusion criteria, 85 different instruments were used. Measures that had been designed specifically for pregnancy were used infrequently, although scales were sometimes modified for the pregnant population. The many different measures that have been used may be a factor that accounts for the inconsistent associations that have been observed.

Deep etonogestrel contraceptive implant placements still occur despite design modifications to the implant inserter. We present a method for outpatient removal of a nonpalpable etonogestrel implant using preprocedure ultrasonography for implant localization followed by removal with a modified vasectomy clamp, a modification of the "U" technique for six-capsule levonorgestrel implant removal.In women with a nonpalpable etonogestrel implant containing barium sulfate, we obtain a radiographic examination to confirm the implant's presence in the upper extremity. Using an 18-MHz linear ultrasound transducer, we identify and mark the implant location on the patient's arm, noting the depth. We remove the implant with local anesthesia in the office using a modified vasectomy clamp through a 5-mm or less skin incision directly over the implant.All three patients referred to our office with nonpalpable etonogestrel implants had successful removal using this technique.Nonpalpable contraceptive implants can be removed in the office using a modified vasectomy clamp after localization with high-frequency ultrasonography. Given the relative infrequency of nonpalpable implant removals, regional expert sites with health care providers experienced in difficult removals should be created for patient referrals.

S / Contraception 92 (2015) 359–414 Objectives: To evaluate the impact of doulas on patients' physical and psychological distress levels during surgical management of first-trimester undesired or failed pregnancy under local anesthesia. Methods: Women were randomized to receive doula support or routine care during office manual vacuum aspiration (MVA). The primary outcome was pain score measured on a 100-mm visual analog scale. Secondary outcomes included satisfaction, validated psychometric scores and women's sense of personal empowerment postprocedurally. Data were collected prior to, immediately following and 1 month following the procedure. Results: The sample consisted of 70 women. While levels of reported pain did not differ between the doula and control groups (70.7±24.5 mm vs. 59.7±32.5 mm, p=.11, respectively), women who received doula support experienced a statistically significant decrease in postprocedure anxiety after we controlled for baseline anxiety (OR, − 11.6; 95% CI, − 22.9 to − 0.2; p= .04). Relief was the most common emotion reported by 60% of women in both groups, regardless of procedure indication. There was no significant difference between groups regarding satisfaction with the procedure (86.2%±23.4 vs. 93.4%±13.5, p=.12), a sense of empowerment (0.11%± 0.31 vs. 0.12%±0.30, p=.93) and perceived ability to cope following the procedure (36.3%±28.1 vs. 42.0%±27.1, p=.39). Of women who received doula support, 97% reported that this was beneficial and that they would recommend a doula to other women having such a procedure. Outcomes: Doula support during office MVA for undesired or failed pregnancies is well received and may address unmet psychosocial needs of women undergoing this procedure. http://dx.doi.org/10.1016/j.contraception.2015.06.044 O16 Determining the accuracy of gestational dating among women presenting for an abortion in Ghana Shellenberg K Ipas, Chapel Hill, NC, USA Antobam S, Edelman A, Griffin R, Voetagbe G Objectives: Our objective was to determine the proportion of women presenting for an abortion in Ghana who could accurately determine whether their pregnancy was less than 13 or 13 weeks or more using a gestational wheel. Methods: We conducted a cross-sectional study among women attending four facilities in Ghana. Interviewers administered the questionnaire, and women were then seen by a provider who assessed gestational age via bimanual exam. We present descriptive statistics for women's recall of last menstrual period and use of the wheel. Using the providers' clinical dating as a reference, we calculated the proportion of participants who accurately determined whether their pregnancy was less than 13 or 13 weeks or more using a gestational wheel. Results: Our sample consisted of 780 women (participation rate was 98%). Twenty-eight percent of respondents used the wheel without verbal instructions. The other 72% were given instructions after trying to complete the task on their own. Sixty percent said the wheel was easy to use. Overall agreement for gestational age between women and providers was 95% (94% agreement for gestational age less than 13 weeks, 1% agreement for gestational age 13 weeks or more). The remainder of women fell into a “low risk disagreement group” and a “high risk disagreement group,” 1% and 4%, respectively. Outcomes: Almost all women were able to use a gestational wheel to date their pregnancy. This simple tool may aid women in the safe use of medication for abortion and therefore decrease morbidity and mortality from unsafe abortion. http://dx.doi.org/10.1016/j.contraception.2015.06.045 O17 University of California, Davis, Sacramento, CA, USA Rounds K, Creinin MD, Hou MY Objectives: We compared follow-up rates, completed abortion and staff utilization among women choosing office or telephone follow-up after medical abortion. Methods: We performed a retrospective chart review of women who had a medical abortion in our office between August 2012 and August 2014. Women chose office or telephone follow-up. Office follow-up involved an ultrasound exam 1–2 weeks after treatment. Telephone follow-up was a standardized interview 1 week after treatment and a urine pregnancy test 30 days after mifepristone. Results: Of 132 medical abortion patients, we excluded seven who were repeat patients. Office and telephone follow-up were chosen by 70 (56%) and 55 (44%) women, respectively. Women's demographic characteristics were similar in both groups. Four (5.7%) and three (5.5%) women who chose office and telephone follow-up were lost to follow-up, respectively (p=1.0). In the telephone group, eight (14.5%) women completed only the 1-week telephone evaluation. Women who chose telephone follow-up were less likely to complete all follow-up (OR, 4.08; 95% CI, 1.12–18.69). The only ongoing pregnancy was in the office follow-up group. Staff rescheduled appointments for 17.4% of women in the office group. Staff called 38.1% and 70.6% of participants at least once at 1 week and 4 weeks, respectively, to complete all assessments. Outcomes: Loss-to-follow-up rates were similar between women who chose office follow-up and those who chose telephone follow-up. However, incomplete evaluations were more common among the latter group. Women who chose telephone follow-up required more attempts to complete assessments than women scheduled for office evaluation. http://dx.doi.org/10.1016/j.contraception.2015.06.046 O18 Contraceptive use and counseling among breast cancer patients: a cross-sectional study Mody S University of California San Diego, San Diego, CA, USA Panelli D, Hulugalle A, Su HI, Parker B, Gorman JR Objectives: This cross-sectional study explored contraceptive counseling and utilization among breast cancer survivors. Methods: We enrolled reproductive-age women with a history of breast cancer in a cross-sectional study. Participants, who were recruited from the Athena Breast Health Network, the Young Survival Coalition and via social media, completed an online survey. We describe the contraceptive utilization and contraception counseling they received. Results: A total of 181 breast cancer survivors participated in this study. Seventy-two percent of respondents (114/159) reported being sexually active during their cancer treatment (surgery, chemotherapy, radiation). Among contraceptive users (n=113), 50% used condoms. Respondents reported that, given the diagnosis of breast cancer, method safety had the biggest influence on their decision. Sixty-two percent (92/149) reported receiving contraceptive counseling from their oncologist; however, 40% of this group did not receive a specific method recommendation. Of respondents who reported receiving contraceptive counseling from their gynecologist, 45% (35/ 78) reported that their gynecologist recommended a copper IUD. Some 52% of respondents (76/146) wanted their oncologist to discuss contraceptive options, and 58% (84/146) preferred to receive this counseling at the time of diagnosis. Outcomes: Breast cancer patients remain sexually active during cancer treatment and predominately use condoms. If they receive counseling from their oncologist, they often do not receive specific method recommenda- tions. Increased efforts should be pursued to educate oncologists about safe, highly effective contraceptive methods for breast cancer patients. Office versus telephone follow-up after medical abortion Chen MJ http://dx.doi.org/10.1016/j.contraception.2015.06.047

Uterine perforation is an infrequent but serious complication of dilation and evacuation (OE). The purpose of this case report is to describe management strategies once a uterine perforation is identified.A 15-year-old female at 15 weeks' gestation presented to a freestanding clinic for elective abortion. After serial cervical dilation, omentum was seen in the suction curette. The patient was transferred to a nearby hospital, she underwent an exploratory laparotomy. A 1.5-cm anterior uterine perforation was found. The uterus was evacuated under direct visualization prior to repair of the defect.Uterine perforation during DE often requires laparotomy to repair the defect and to evaluate for injury to adjacent organs. Evacuation can be completed transcervically under direct visualization or through the perforation site.

INTRODUCTION: Emergency medicine physicians can decrease the risk of unintended pregnancy in at-risk women presenting to the emergency department through consistent emergency contraception provision. We assessed emergency medicine residents' practice patterns and emergency contraception provision barriers to better understand emergency medicine resident training on emergency contraception. METHODS: An online survey was e-mailed to U.S.-based emergency medicine residency program directors for resident distribution. Current residents caring for reproductive-aged women were eligible. Survey questions assessed demographics, prescription and counseling patterns, and provision barriers. RESULTS: Three hundred forty-five participants met inclusion criteria and represented all training years and U.S. regions. Mean age was 29.9 years, and 50.3% were female. Most participants reported an academic (74.8%) and nonreligious (88.6%) hospital affiliation. A total of 24.7% of respondents prescribed emergency contraception over the last 6 months. Although 71.2% reported "always" offering emergency contraception after sexual assault, only 19.5% "always" offered emergency contraception after unprotected consensual sex. The most common emergency contraception provision barriers were lack of knowledge (37.5%) and lack of follow-up (39.1%). Respondents were more likely to prescribe emergency contraception if it was on formulary (odds ratio [OR] 18.8, 95% confidence interval [CI] 8.3-42.4) or a protocol for sexual assault victims included emergency contraception (OR 5.9, 95% CI 2.3-11.0). Participants were less likely to prescribe emergency contraception if they were first-year residents (OR 3.0, 95% CI 1.6-4.7) or if they reported lack of sufficient knowledge (OR 2.3, 95% CI 1.3-4.2). CONCLUSIONS: Emergency medicine residents often care for women at risk of unintended pregnancy yet have low emergency contraception prescription rates. Emergency department changes and improved education may increase emergency contraception provision to eligible women. Language: en