On June 24, 2022, the Supreme Court overturned Roe v. Wade, which will limit legal abortion in many areas of the U.S. Over half of abortions in the U.S. are performed using medication as opposed to surgical techniques. With widespread access to agents that are used for medication abortion, there may be an increase in emergency department presentations related to improper or unsupervised use of these medications. Show
MethodsThis narrative review focuses on the contraindications, adverse effects, and toxicities of the most common agents used for medication abortion in the U.S. ResultsMedications included in this review are mifepristone, misoprostol, and methotrexate. Each of these medications has a unique adverse effect and toxicity profile. ConclusionAgents used for medication abortion have unique contraindications and adverse effects. Improper or unsupervised use may occur in the setting of limited abortion access and emergency medicine physicians are on the front lines in managing these presentations. IntroductionOn May 2, 2022, a draft of the Supreme Court decision for the Dobbs. v. Jackson Women's Health Association was leaked to the public. The case surrounds a 2018 Mississippi law that bans the majority of abortions after 15 weeks' gestation, a constitutional right that was established in 1973 with the Roe v. Wade decision [1]. Since Roe v. Wade, there have been many legal challenges to the right to abortion, and many states have enacted laws that have increasingly restricted abortion access, but have fallen short of making abortion illegal. The legal right to abortion was upheld but weakened in the Planned Parenthood of Southeastern Pennsylvania v. Casey case of 1992 [2]. In the leaked draft of the majority decision of Dobbs case, the Court upholds the Mississippi law, overturning the Roe and Casey decisions. Previously lower courts have blocked the Mississippi law from being enacted. The ruling became final on June 24, 2022, overturning Roe, with some states enacting trigger laws that day [3]. With the Constitutional right to an abortion abolished, access to legal abortion in the U.S. may be limited in many states. At the time of the draft leak, it was estimated 13 states had “trigger laws” which would go into effect if Roe is overturned, banning abortion in those states. In some states, trigger laws went into effect the day the ruling was announced, while in other states it is an actively evolving situation [3]. Not only do these laws ban abortion, but women who obtain abortions face significant repercussions, including imprisonment [4]. One unintended consequence of limiting abortion access is an increase in illegal, and often unsafe abortions. These abortions may be medical or surgical in nature and may or may not be performed with appropriate physician training or oversight. In addition, women may avoid seeking care for abortion-related complications due to fear of repercussions [5]. There are several U.S. Food and Drug Administration (FDA) approved medications that are used for medication abortions and the treatment of ectopic pregnancy. In addition, there are many herbal products and chemicals that have been used as abortifacients. Finally, women may overdose on medications in an effort to terminate an unwanted pregnancy. Each agent has not only its own unique toxicity to the pregnant woman, but also potential teratogenic effects to the fetus. With increasingly limited access to legal abortion, physicians must be cognizant of the toxicity of agents used in an under or unsupervised manner as abortifacients or the possibility of patients receiving counterfeit, mislabeled, or adulterated medications [6]. The purpose of this narrative review is to provide context as to how these agents are used in medication abortion and to discuss contraindications, adverse effects, and toxicity of FDA approved pharmaceuticals that are approved or used off label in medication abortions in order to provide guidance to physicians who treat patients presenting with adverse effects. This is particularly important as medication abortions are anticipated to be the primary means of access to abortion in states with restrictions because there is controversy as to whether a state can ban an FDA approved medication. Section snippetsFDA approved agents used for medication abortionIt has been estimated that over 50% of abortions in the United States are medical and this number has increased overtime [7]. Medication abortion is considered a safe and effective means of pregnancy termination up to 10 weeks gestation [8,9]. The regimen endorsed by the World Health Organization and what is commonly used in the U.S. includes two medications, mifepristone and misoprostol; however, when mifepristone is unavailable or if there are cost considerations or contraindications, ConclusionsThe Supreme Court ruling that overturned Roe v. Wade has limited abortion access in the U.S. With greater accessibility to medication abortion compared to surgical abortion, it is anticipated that women may turn to this option in seeking termination. Due to legal restrictions, women may take these agents in an under supervised or clandestine manner, which may predispose to toxicity for both the mother and the fetus. Delayed presentation due to fear of repercussions may exacerbate toxicity and Funding supportNo funding support was provided for this study. Financial disclosuresThe authors have no financial relationships relevant to this article to disclose. CRediT authorship contribution statementMaryann Mazer-Amirshahi: Writing – review & editing, Writing – original draft, Investigation, Conceptualization. Peggy Ye: Writing – review & editing, Resources, Conceptualization. Declaration of Competing InterestThe authors have no conflicts of interest to disclose. References (32)
Facing counterfeit medications in sexual medicine A systematic scoping review on social strategies and technological solutionsSex Med(2021) Read Justice Alito's initial draft abortion opinion which could overturn Roe v. Wade. PoliticoSCOTUSblog.comSupreme Court overturns Roe v. Wade, ending right to abortion upheld for decadesWhat is a trigger law? And which states have them? The New York timesState abortion policies and maternal death in the United States, 2015–2018Am J Public Health(2021)
Research article The American Journal of Emergency Medicine, Volume 61, 2022, pp. 18-28 Show abstractNavigate Down Carbon monoxide (CO) poisoning can cause serious neurological sequelae. However, there is neither effective treatment strategy nor reliable indicators to determine the prognosis of patients with CO poisoning. The present study aimed to observe the changes of neurological function score, disease severity score, cerebral oxygen utilization (O2UCc), bispectral (BIS) index and neuron-specific enolase (NSE) concentration, and to elucidate the clinical significance of these potential indicators and the neuroprotective effect of mild hypothermia on brain injury in patients with severe acute CO poisoning. A total of 277 patients with acute severe CO poisoning from 2013 to 2018 were enrolled in our hospital. Patients were divided into three groups according to their body temperature on the day of admission and their willingness to treat: a fever group (n = 78), a normal temperature group (NT group, n = 113), and a mild hypothermia group (MH group, n = 86). All patients were given hyperbaric oxygen therapy, while those in the MH group received additional mild hypothermia treatment. The severity of the disease, the neurobehavioral status, the incidence of delayed encephalopathy after acute carbon monoxide poisoning (DEACMP), and other indicators including BIS, O2UCc, NSE were further evaluated in all patients at given time-points. Mild hypothermia therapy improved the prognosis of patients with CO poisoning, significantly decreased the value of O2UCc and NSE, and up-regulated BIS. The incidence of DEACMP at 6 months was 27% in the fever group, 23% in the NT group, and 8% in the MH group. The values of Glasgow-Pittsburgh coma scale (G-P score), BIS index and NSE were closely related to the occurrence of DEACMP, the cutoff values were 12.41, 52.17 and 35.20 ng/mL, and the sensitivity and specificity were 79.3%, 77.6%, 79.3% and 67.6%, 89.5%, 88.6% in the receiver operating characteristic curve (ROC), respectively. Early mild hypothermia treatment could significantly reduce the severity of brain injury after CO poisoning, and might be further popularized in clinic. G-P scores, NSE and BIS index can be regarded as the prediction indicators in the occurrence and development of DEACMP. The study protocol was granted from Qingdao University Research Ethics Committee (Clinical trial registry and ethical approval number: QD81571283). Research article The American Journal of Emergency Medicine, Volume 61, 2022, pp. 217-218 Research article Development of a model to measure the effect of off-balancing vectors on the delivery of high-quality CPR in a moving vehicleThe American Journal of Emergency Medicine, Volume 61, 2022, pp. 158-162 Show abstractNavigate Down We sought to develop a model to measure the acceleration and jerk vectors affecting the performance of High-Quality Cardiopulmonary Resuscitation (HQ-CPR) during patient transport. Three participants completed a total of eighteen rounds of compression only HQ-CPR in a moving vehicle. The vehicle was driven in a manner that either minimized or increased linear and angular vectors. The HQ-CPR variables measured were compression fraction (CF%), and percentages of compressions with correct depth > 5 cm (D%), rate 100–120 (R%), full recoil (FR%), and hand position (HP%). A composite HQ-CPR score was calculated: ((D% + R% + FR% + HP%)/4) * CF%). Linear and gyroscopic data were measured in the X, Y, and Z axes. The perceived difficulty in performing HQ-CPR was measured with the Borg Rating of Perceived Exertion Scale. HQ-CPR data, linear vector data, and gyroscopic data were successfully recorded in all trial evolutions. Univariate regression analysis demonstrated that HQ-CPR was negatively affected by increasing magnitudes of linear acceleration (B = −0.093%/m/s2, 95% CI [−0.17 – −0.02), p = 0.02], linear jerk (B = −0.134%/m/s3, 95% CI [−0.26 – −0.01], p = 0.04), angular velocity (B = −0.543%/radian/s, 95% CI [−0.98 – −0.11], p = 0.02), and angular acceleration (B = 0.863%/radian/s2, 95% CI [−1.69 – −0.03], p = 0.04). Increasing vectors were negatively associated with FR% and R%. No difference was seen in D%, HP%, or CF%. Borg Rating of Perceived Exertion was greater in dynamic driving evolutions (8 ± 1 vs 3.5 ± 1.53, p = 0.02). This model reliably measured linear and angular off-balancing vectors experienced during the delivery of HQ-CPR in a moving vehicle. In this preliminary report, compression rate and full recoil appear to be HQ-CPR variables most affected in a moving vehicle. Research article Usefulness of sequential organ failure assessment score on admission to predict the 90-day mortality in patients with exertional heatstroke: An over 10-year intensive care surveyThe American Journal of Emergency Medicine, Volume 61, 2022, pp. 56-60 Show abstractNavigate Down Despite a growing understanding of exertional heatstroke (EHS), there is a paucity of clinical evidence for risk-stratification of patients with EHS. The objective of this study was to identify an appropriate scoring system for prognostic assessment of EHS. This was a retrospective cohort study of all patients with EHS admitted to intensive care unit (ICU) of the General Hospital of Southern Theatre Command of PLA between October 2008 and May 2019. Inflammatory indices and organ function parameters at admission, the Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, Sequential Organ Failure Assessment (SOFA) scores, and Glasgow Coma Scale (GCS) score were collected. Risk factors for 90-day mortality were identified using multivariate Cox proportional hazard risk regression model. 189 patients (all male) were finally included, with a median age of 21.0 years (IQR 19.0–27.0), median APACHE II score of 11.0 (IQR 8.0–16.0), median SOFA score of 3.0 (IQR 2.0–6.0), and median GCS score of 12.0 (IQR 7.0–14.0). There were 166 survivors (87.8%) and 23 non-survivors (12.2%). Compared with survivor group, non-survivors had higher incidence of severe organ damage, including rhabdomyolysis (46.1% vs 63.6%), disseminated intravascular coagulation (25.6% vs 90.0%), acute liver injury (69.4% vs 95.7%), and acute kidney injury (36.6% vs 95.7%). Multivariate Cox risk regression model showed that SOFA score was an independent risk factor for 90-day mortality, with an optimal cutoff score of 7.5. SOFA score may be a clinically useful predictor of death in EHS. Prospective studies are required to confirm the effectiveness of SOFA score and the optimal cutoff level. Research article Helicopter versus ground ambulance transport for interfacility transfer of critically ill childrenThe American Journal of Emergency Medicine, Volume 61, 2022, pp. 44-51 Show abstractNavigate Down Following initial stabilization, critically ill children often require transfer to a specialized pediatric hospital. While the use of specialized pediatric transport teams has been associated with improved outcomes for these patients, the additional influence of transfer mode (helicopter or ground ambulance) on clinical outcomes remains unknown. We investigated the association between transport mode and outcomes among critically ill children transferred to a single pediatric hospital via a specialized pediatric transport team. We designed a retrospective cohort study to reduce indication bias by limiting analysis to patients for whom a helicopter transport was initially requested. We compared outcomes for those who ultimately traveled via helicopter, and for those who ultimately traveled via ground ambulance due to non-clinical factors. We compared transport times, in-hospital mortality, and hospital length of stay by transport mode. Transport time in minutes was shorter for helicopter transports (median = 143, interquartile range [IQR]: 118–184) compared to ground ambulance transports (median = 289, IQR: 213–258; difference in medians = 146, 95% CI: 12 to 168, p < 0.001). In unadjusted analysis, helicopter transport was not associated with a difference in in-hospital mortality (helicopter = 6.0%, ground ambulance = 7.0%; 95% CI for difference: −6.6% to 3.3%; p = 0.64) but was associated with a statistically significant reduction in median hospital days (helicopter = 4, ground ambulance = 5; 95% CI -3 to 0; p = 0.04). In adjusted analyses, there were no statistically significant associations. These results were consistent across sensitivity analyses. Among critically ill pediatric patients without traumatic injuries transported by a specialty team, those patients who would have been transferred by helicopter if available but were instead transferred by ground ambulance reached their site of definitive care approximately 2.5 h later. Helicopter transport for these patients was not associated with in-hospital mortality, but was potentially associated with reduced hospital length of stay. Research article Transient synovitis of the hip: Current practice and risk of misdiagnosisThe American Journal of Emergency Medicine, Volume 61, 2022, pp. 1-6 Show abstractNavigate Down Transient synovitis (TS) is a common and benign cause of hip pain in children, but must be distinguished from more serious entities such as septic arthritis, osteomyelitis, and pyomyositis. Our objectives were to determine the risk of missed bacterial musculoskeletal infection and rates of diagnostic testing in children diagnosed with TS. We performed a cohort study using the Pediatric Heath Information System of children 1–10 years diagnosed with TS in the ED. We determined rates of missed bacterial musculoskeletal infection (defined as a new diagnosis of septic arthritis, osteomyelitis, or pyomyositis within 14 days of initial ED visit). We described the initial diagnostic evaluation and ED management of children diagnosed with TS and variability between sites. We analyzed 6419 encounters from 37 hospitals. 62 (1.0%, 95%CI: 0.7–1.2%) children were diagnosed with a missed bacterial musculoskeletal infection. Children with missed infection were younger than those without (median age 2.6 vs. 4.6 years, p < 0.01). Serum laboratory testing was performed in 76% of encounters with minimal variation across sites. There was significant variation in the rates of hip ultrasound by site (2 to 92%), which has increased in use over time (from 42% in 2016 to 62% in 2021). In this large observational study, missed bacterial musculoskeletal infection in children diagnosed with TS was rare but more common in younger children. The optimal combination of bloodwork and radiographic testing, especially ultrasound, to distinguish TS from more serious disease remains unclear. What is the management of intrauterine fetal death?For medical management of IUFD at ≥ 14 to ≤ 28 weeks: Suggest the use of combination mifepristone plus misoprostol over misoprostol alone. Suggested regimen: 200 mg mifepristone administered orally, followed 1–2 days later by repeat doses of 400 μg misoprostol administered sublingually or vaginally every 4–6 hours.
Does misoprostol cause fetal death?Misoprostol is a very powerful drug in late pregnancy and its use in a high dose (i.e. over 50 µg vaginally) with a live fetus can easily result in fetal death and uterine rupture.
What is the most common cause of intrauterine fetal death?Stillbirth has many causes: intrapartum complications, hypertension, diabetes, infection, congenital and genetic abnormalities, placental dysfunction, and pregnancy continuing beyond forty weeks. It is a catastrophic event with lasting consequences on all of society.
What is the difference between IUFD and stillbirth?The Perinatal Mortality Surveillance Report (CEMACH)3 defined stillbirth as 'a baby delivered with no signs of life known to have died after 24 completed weeks of pregnancy'. Intrauterine fetal death refers to babies with no signs of life in utero.
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