Kate Shaw, MD

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Obstetrics & Gynecology

Work and Education

Professional Education

Albany Medical Center, Albany, NY, 05/31/2007


Oregon Health Science University, Portland, OR, 2011


Stanford School of Medicine, Stanford, CA, 06/30/2013

Board Certifications

Complex Family Planning, American Board of Obstetrics and Gynecology

Obstetrics & Gynecology, American Board of Obstetrics and Gynecology

All Publications

Cabergoline for Lactation Inhibition After Second-Trimester Abortion or Pregnancy Loss: A Randomized Controlled Trial. Obstetrics and gynecology Henkel, A., Johnson, S. A., Reeves, M. F., Cahill, E. P., Blumenthal, P. D., Shaw, K. A. 2023; 141 (6): 1115-1123


To assess cabergoline's efficacy at decreasing breast symptoms after second-trimester abortion or pregnancy loss.This was a double-blinded, block-randomized superiority trial comparing cabergoline 1 mg once to placebo for preventing bothersome breast engorgement after second-trimester uterine evacuation. We enrolled pregnant people at 18-28 weeks of gestation who were English- or Spanish-speaking and without contraindication to the study drug. Participants completed a validated, piloted, electronic survey at baseline and at multiple timepoints through 2 weeks postprocedure to assess breast symptoms, side effects, and bother. Our primary outcome was any breast symptoms (a composite of engorgement, milk leakage, tenderness, and need for pain relief) on day 4; we planned to enroll 80 patients to show a 30% difference in breast symptoms (80% power, =0.049). A subgroup of participants returned for serum prolactin levels.After screening 150 patients from April 2021 to June 2022, we enrolled 73 participants. Baseline demographics were balanced between groups: median gestational age was 21 weeks (range 18-26 weeks), 56.2% of participants were nulliparous, 34.2% self-identified as Hispanic, and 37.0% had public insurance. At baseline, reported breast symptoms were similar between groups. Among 69 participants who returned surveys on day 4, significantly fewer participants receiving cabergoline reported any breast symptoms compared with placebo (27.8% vs 97.0%, P<.001) (primary outcome) and fewer reported significant bother (2.8% vs 33.3%, P=.001) (secondary outcome). These differences persisted through day 14. Reported incidence and severity of bother from side effects were similar between groups: most common were constipation, fatigue, and headache. Serum prolactin levels were similar at baseline. On day 4, mean serum prolactin level was 6.5 ng/mL (SD 2.2) for those who received cabergoline and 18.0 ng/mL (SD 5.9) for placebo (P=.049).Cabergoline is an effective and well-tolerated strategy to prevent breast symptoms after second-trimester abortion or pregnancy, NCT04701333.

View details for DOI 10.1097/AOG.0000000000005190

View details for PubMedID 37486652

Discovery of an Ectopic Pregnancy after Attempted Self-Managed Abortion. The New England journal of medicine Beshar, I., Liu, S. M., Shaw, K. A., Henkel, A. 2023; 388 (3): 278-279

View details for DOI 10.1056/NEJMc2214213

View details for PubMedID 36652361

New Gaps and Urgent Needs in Graduate Medical Education and Training in Abortion. Academic medicine : journal of the Association of American Medical Colleges Beasley, A. D., Olatunde, A., Cahill, E. P., Shaw, K. A. 2023


Abortion is essential health care, and abortion training and education are essential at all levels of medical education. Among the most common procedures performed in obstetrics and gynecology (OB/GYN), abortion is a core competency for OB/GYN residency programs. For nearly 50 years, the procedure was federally protected by the U.S. Supreme Court's January 22, 1973, Roe v Wade decision. On June 24, 2022, amidst increasing state restrictions limiting abortion access, the Court's decision on Dobbs v Jackson Women's Health Organization effectively reversed Roe. As a result, immediate bans on abortion went into effect across the country, removing access to abortion for millions of people and newly limiting training and education in this core competency for many medical residents. As of June 2022, nearly half of U.S. OB/GYN residency programs and more than 40% of residents are located in states that have banned or are likely to ban abortion. In states where abortion is restricted or illegal, states must adapt quickly to ensure their residents meet training requirements. This adaptation may include developing and leveraging relationships with programs in states where access is protected, depending on simulation, and placing greater emphasis on education and training in pregnancy loss management and postabortion care. None of these is a comprehensive solution and even all together, they are insufficient to train residents and medical students. Ultimately, many future physicians will not receive the training they need to provide full reproductive health care to their pregnant patients. Legal and other systems of support are needed to ensure that current and future physicians can provide compassionate, evidence-based reproductive health care, including essential abortion care.

View details for DOI 10.1097/ACM.0000000000005154

View details for PubMedID 36656271

Lactogenesis and breastfeeding after immediate versus delayed birth-hospitalization insertion of etonogestrel contraceptive implant: A non-inferiority trial. American journal of obstetrics and gynecology Henkel, A., Lerma, K., Reyes, G., Gutow, H., Shaw, J. G., Shaw, K. A. 2022


BACKGROUND: Initiating a progestin-based contraceptive prior to the drop in progesterone required to start lactogenesis stage II (LII) could theoretically impact lactation. Previous studies have shown that initiating progestin-based contraception in the postnatal period prior to birth-hospitalization discharge has no detriment on breastfeeding initiation or continuation compared to interval initiation as an outpatient; however, there is currently no breastfeeding data on the impact of initiating the etonogestrel contraceptive implant (ETG-implant) in the early postnatal period immediately in the delivery room.OBJECTIVE: This study examined the effect of delivery room vs delayed birth-hospitalization contraceptive ETG-implant insertion on breastfeeding outcomes.STUDY DESIGN: This is a non-inferiority randomized controlled trial to determine if time to LII (initiation of copious milk secretion) differs by timing of ETG-implant insertion during the birth-hospitalization. We randomly assigned pregnant people to insertion at 0-2 hours (delivery room) versus 24-48 hours (delayed) post-delivery. Participants intended to breastfeed, desired a contraceptive implant for postpartum contraception, were fluent in English or Spanish, and without an allergy or contraindication to the ETG-implant. We collected demographic information and breastfeeding intentions at enrollment. Onset of LII was assessed daily using a validated tool. The non-inferiority margin for the mean difference in time to LII was defined as 12 hours in a per-protocol analysis. Additional electronic surveys collected data on breastfeeding and contraceptive continuation at 2 and 4 weeks, 3, 6, and 12 months.RESULTS: We enrolled and randomized 95 participants; 77 participants were included in the modified intention-to-treat analysis (n=38 in the delivery room group and n=39 in the delayed group) after excluding eighteen due to withdrawing consent, changing contraceptive or breastfeeding plans, or failing to provide primary outcome data. 69 participants are included in the as-treated analysis (n=35 delivery room, n=34 delayed); 8 participants who received the ETG-implant outside the protocol windows were excluded and 2 participants from the delivery room group received the ETG-implant at 24-48 hours and were analyzed with the delayed group. Participants were similar between groups in age, gestational age, prior breastfeeding experience. Delivery room insertion was non-inferior to delayed birth-hospitalization insertion in time to LII (delivery room: [mean+standard deviation] 65+25 hours; delayed: 73+61 hours, mean difference -9 hours, 95% confidence interval [CI] -27, 10). Onset of LII by postpartum day 3 was not significantly different between groups. Lactation failure occurred in 5.5% (n=2) participants in the delayed group. Ongoing breastfeeding rates did not differ between groups with decreasing rates of any/exclusive breastfeeding over the first postpartum year. Most people continued to use the implant at 12 months, which did not differ by group.CONCLUSION: Delivery room insertion of the contraceptive ETG-implant does not delay onset of lactogenesis when compared to initiation later in the birth-hospitalization and therefore should be offered routinely as part of person-centered postpartum contraceptive counseling regardless of breastfeeding intentions.

View details for DOI 10.1016/j.ajog.2022.08.012

View details for PubMedID 35964661

Impact of a Potential 20-Week Abortion Ban on Likelihood of Completing Required Views in Second-Trimester Fetal Anatomy Ultrasound. American journal of perinatology Henkel, A., Beshar, I., Cahill, E. P., Blumenfeld, Y. J., Chueh, J., Shaw, K. A. 2022


The aim of this study was to quantify the likelihood of assessing all mandated fetal views during the second-trimester anatomy ultrasound prior to the proposed federal 20-week abortion ban.Retrospective cohort study of a random sample of 1,983 patients undergoing anatomy ultrasound in 2017 at a tertiary referral center. The difference in proportion of incomplete anatomic surveys prior compared with after 20-week gestation was analyzed using X 2 and adjusted logistic regression; difference in mean days elapsed from anomaly diagnosis to termination tested using t-tests and survival analysis.Incomplete views were more likely with initial ultrasound before 20 weeks (adjusted relative risk: 1.70; 95% confidence interval: 1.50-1.94); 43.5% versus 26.1% were incomplete before and after 20 weeks, respectively. Fetal structural anomalies were identified in 6.4% (n=127/1,983) scans, with 38.0% (n=49) identified at follow-up after initial scan was incomplete. 22.8% (n=29) with an anomaly terminated.A complete assessment of fetal views during an anatomy ultrasound prior to 20-week gestation is often not technically feasible. Legislation limiting abortion to this gestational age would greatly impact patient's ability to make informed choices about their pregnancies. It is often not technically possible to complete anatomy ultrasound prior to 20-week gestation.. Often, anomalies are missed during early, incomplete anatomy ultrasounds.. After the diagnosis of a structural anomaly, one in five chose to terminate the pregnancy..

View details for DOI 10.1055/s-0042-1749138

View details for PubMedID 35576967

A Comparison of Paracervical Block Volumes Before Osmotic Dilator Placement: A Randomized Controlled Trial. Obstetrics and gynecology Shaw, K. A., Lerma, K., Hughes, T., Hastings, C., Fok, W. K., Blumenthal, P. D. 2021


OBJECTIVE: To evaluate whether a 12-mL paracervical block is noninferior to a 20-mL block in reducing pain with osmotic dilator insertion.METHODS: In this single-blinded noninferiority trial, we randomized individuals undergoing insertion of osmotic dilators before second-trimester abortion to receive either a 12-mL or 20-mL 1% lidocaine paracervical block. The primary outcome was pain immediately after insertion of osmotic dilators. Prespecified secondary outcomes included pain with paracervical block administration, overall pain, and side effects, with 88 participants being required for a noninferiority margin of 15 mm on a 100-mm visual analog scale assuming an SD of 28. We analyzed data using Wilcoxon rank sum, chi2, and t tests and performed analysis of variance to account for repeated measures. Secondary analysis included multivariable regression to explore potential confounders.RESULTS: From January 2018 to October 2020, of 232 eligible individuals, 174 were approached and 96 randomized (48 participants to each group); 91 were available for analysis (45: 12 mL, 46: 20 mL). Group demographics were similar, with a mean gestation of 21 weeks and four osmotic dilators placed. The 12-mL paracervical block was noninferior to the 20-mL paracervical block for pain with osmotic dilator insertion with a difference in means of -1.36 (95% CI -12.56 to 9.85) favoring 12 mL. Median pain scores after dilator placement were 47 mm (interquartile range 22-68) and 50 mm (interquartile range 27-67) in 12-mL compared with 20-mL paracervical block, respectively (P=.81). No difference was seen in median pain at baseline, with paracervical block administration, postprocedure or with overall pain or experience. At least one lidocaine-related side effect occurred in 4% of participants in the 12-mL group compared with 13% for those receiving 20 mL (P=.15), with metallic taste, ringing in ears, and lightheadedness being most common.CONCLUSION: A 12-mL paracervical block is noninferior to a 20-mL block for pain reduction with osmotic dilator insertion.CLINICAL TRIAL REGISTRATION:, NCT03356145.

View details for DOI 10.1097/AOG.0000000000004485

View details for PubMedID 34352829

Transcutaneous Electrical Nerve Stimulation for Pain Management of Aspiration Abortion up to 83 Days of Gestation: A Randomized Controlled Trial. Obstetrics and gynecology Lerma, K., Goldthwaite, L. M., Blumenthal, P. D., Shaw, K. A. 2021


To evaluate high-frequency, high-intensity transcutaneous electrical nerve stimulation (TENS) as an inexpensive, noninvasive pain management approach for first-trimester aspiration abortion.We conducted a noninferiority, single-blind, randomized controlled trial of patients seeking aspiration abortion at up to 83 days of gestation. Participants received TENS (placed posteriorly, T10-L1 and S2-S4) or intravenous (IV) sedation (fentanyl, midazolam). The primary outcome was pain with aspiration, as self-reported by visual analog scale (VAS, 100 mm). To detect at least a 15 mm mean difference on the 100 mm VAS with 90% power and a significance level of .05, a total of 90 participants were required.Between January 2018 and October 2019, we enrolled 109 participants (55 TENS, 54 IV). Participant median gestation was 53 days (range 36-82) in the TENS group and 58 days (range 35-82) in the IV group (P=.65). Group demographics and clinical histories were similar. Intention-to-treat analysis (n=109) yielded noninferior results for the primary outcome (mean difference 4.8 mm, 95% CI -5.9 to 13.5 mm). In the per-protocol analysis, 9 (16%) in the TENS group were excluded after receiving IV sedation; 100 participants were included (46 TENS, 54 IV). Median (range) reported VAS for aspiration was 73 mm (13-97) and 66 mm (0-99) in the TENS and IV groups, respectively (P=.40). With a mean difference of 4.4 mm (95% CI -5.6 to 14.5 mm), we found TENS to be noninferior to IV. Physicians underestimated participant pain, perceiving pain to be 34 mm (6-91) in the TENS group and 25 mm (0-83) in the IV group (P=.003).We found TENS to be a noninferior alternative to IV sedation for aspiration pain during first-trimester abortion. Expanding pain management options can improve quality of and access to abortion. Transcutaneous electrical nerve stimulation could be a standalone or adjunct approach for abortion pain management for those without access to or are ineligible to receive IV sedation due to the lack of sedation practitioner, designated driver, or local, NCT03187002.

View details for DOI 10.1097/AOG.0000000000004502

View details for PubMedID 34352845

Standardizing abortion education: what medical schools can learn from residency programs. Current opinion in obstetrics & gynecology Burns, R. M., Shaw, K. A. 2020


PURPOSE OF REVIEW: With over 50 million abortions annually and 25% of pregnancies ending in abortion worldwide, abortion is one of the most common medical procedures. Yet abortion-related topics are glaringly absent from medical school curricula in the USA with half of medical schools including no formal training or only a single lecture. We explore abortion education in US medical schools and Obstetrics and Gynecology (Ob/Gyn) residency programs. Specifically, we review efforts to improve and standardize this training.RECENT FINDINGS: Despite documented interest in both learning and in the benefits of early exposure, medical students face a lack of educational opportunities in abortion care. Meanwhile, Ob/Gyn residency has standardized requirements for abortion care, greatly improving training and education, despite persistent challenges in universal compliance with these standards.SUMMARY: Education in abortion care is crucially important in fostering and training future abortion providers, thereby ensuring and expanding access to safe abortion. The improvements made by standardizing abortion education in Ob/Gyn residency should encourage similar efforts in medical school in order to increase earlier and wider exposure to future physicians of all specialties. On a national level, standardizing exams for medical students by which to evaluate their understanding of abortion care would hold schools accountable for medical student education.

View details for DOI 10.1097/GCO.0000000000000663

View details for PubMedID 32969850

Self-administered lidocaine gel for local anesthesia prior to osmotic dilator placement: a randomized trial CONTRACEPTION Schivone, G. B., Lerma, K., Montgomery, C., Wright, P., Conti, J. A., Blumenthal, P. D., Shaw, K. A. 2019; 99 (3): 14851
Self-Administered Vaginal Lidocaine Gel for Pain Management with Intrauterine Device Insertion: A Blinded, Randomized Controlled Trial. American journal of obstetrics and gynecology Conti, J. A., Lerma, K., Schneyer, R., Hastings, C. V., Blumenthal, P. D., Shaw, K. A. 2018


BACKGROUND: A major barrier to intrauterine device use is fear of pain during insertion. Trials exploring analgesic interventions for intrauterine device insertion have yielded mixed results, and no standardized pain management guidelines currently exist for this procedure. In an abortion-related study, self-administered lidocaine gel over a prolonged time interval showed promise as a method of pain control.OBJECTIVE(S): To assess pain control with intrauterine device insertion after patient-administered lidocaine gel compared to placebo.STUDY DESIGN: We conducted a randomized, blinded trial of women undergoing levonorgestrel or copper intrauterine device insertion in an outpatient gynecology clinic between July 2016 and April 2017. Participants self-administered either 20 mL of 2% lidocaine gel or placebo gel vaginally at least 15-minutes prior to intrauterine device insertion. No other analgesics were administered. The primary outcome was pain during intrauterine device insertion, measured on a 100-mm visual analog scale (VAS, 0 being "no pain" and 100 being "worst pain imaginable"). Secondary outcomes included anticipated and baseline pain and pain with speculum insertion and tenaculum placement. In a post-procedure questionnaire, participants reported acceptability of vaginal gel and willingness to wait for pain control. Median values were assessed due to the non-normal distribution of visual analog scale scores using the Mann-Whitney U test. Predictors of IUD insertion pain were assessed using a multiple linear regression.RESULTS: In total, 220 women were randomized and 215 were included in analysis (108 in lidocaine gel, 107 in placebo gel groups). Median (range) time from gel administration to speculum insertion was 21 (14-74) and 20 (12-43) minutes in the lidocaine and placebo groups, respectively (p=.13). The median pain scores during intrauterine device insertion were not significantly different: 65 (1-99) mm in the lidocaine group and 59 (5-100) mm in the placebo group (p=.09). Among secondary outcome time points, only median pain scores at speculum insertion were significantly different between the lidocaine and placebo groups (7 (0-81) mm versus 11 (0-80) mm, respectively; p=.046). Anticipated pain and menstrual pain were both predictors of pain with IUD insertion. The majority of women in both groups found the amount of vaginal leakage following gel insertion to be acceptable (>80%). Ninety-two percent (n= 194) of participants stated they would be willing to wait before intrauterine device placement for a potential analgesic effect.CONCLUSION(S): Self-administered lidocaine gel at least 15-minutes before intrauterine device insertion does not appear to reduce pain compared with placebo, but may help with speculum insertion. We found that women are willing to extend visit time to gain pain control. Self-administration of local anesthetic is acceptable to patients and should be considered in future research.

View details for PubMedID 30444982

Long-Acting Reversible Contraceptive Placement Among Active-Duty U.S. Army Servicewomen. Obstetrics and gynecology Erickson, A. K., Nelson, D. A., Shaw, J. G., Loftus, P. D., Kurina, L. M., Shaw, K. A. 2017; 129 (5): 800-809


To quantify uptake of long-acting reversible contraceptives (LARC)-intrauterine devices (IUDs) and hormonal implants-among U.S. Army active-duty female soldiers and identify characteristics associated with uptake.This retrospective cohort study used the Stanford Military Data Repository, which includes all digitally recorded health encounters for active-duty U.S. Army soldiers from 2011 to 2014. We analyzed data from women aged 18-44 years to assess rates of LARC initiation using medical billing codes. We then evaluated predictors of LARC initiation using multivariable regression.Among 114,661 servicewomen, 14.5% received a LARC method; among those, 60% received an IUD. Intrauterine device insertions decreased over the study period (38.7-35.9 insertions per 1,000 women per year, =0.14, 95% confidence interval [CI] -0.23 to -0.05, P<.05), whereas LARC uptake increased, driven by an increase in implant insertions (20.3-35.4/1,000 women per year, =0.41, CI 0.33-0.48, P<.001). Younger age was a positive predictor of LARC uptake: 32.4% of IUD users and 62.6% of implant users were in the youngest age category (18-22 years) compared with 9.6% and 2.0% in the oldest (36-44 years). The likelihood of uptake among the youngest women (compared with oldest) was most marked for implants (adjusted relative risk 7.12, CI 5.92-8.55; P<.001). A total of 26.2% of IUD users had one child compared with 13.2% among non-LARC users (adjusted relative risk 1.94, CI 1.85-2.04, P<.001). The majority (52.2%) of those initiating IUDs were married, which was predictive of uptake over never-married women (adjusted relative risk 1.52, CI 1.44-1.59, P<.001).Among servicewomen, we observed low but rising rates of LARC insertion, driven by increasing implant use. Unmarried and childless soldiers were less likely to initiate LARC. These findings are consistent with potential underutilization and a need for education about LARC safety and reversibility in a population facing unique consequences for unintended pregnancies.

View details for DOI 10.1097/AOG.0000000000001971

View details for PubMedID 28383371

Self-Administered Lidocaine Gel for Pain Control With First-Trimester Surgical Abortion: A Randomized Controlled Trial. Obstetrics and gynecology Conti, J. A., Lerma, K., Shaw, K. A., Blumenthal, P. D. 2016; 128 (2): 297-303


To compare pain control at various time points during first-trimester surgical abortion using a patient-administered lidocaine gel compared with a traditional lidocaine paracervical block.We conducted a randomized controlled trial of women undergoing surgical abortion at less than 12 weeks of gestation in an outpatient setting. The primary outcome was pain at cervical dilation as measured on a 100-mm visual analog scale. A sample size of 142 participants was planned to detect a 15-mm or greater difference on the 100-mm visual analog scale with 90% power and a significance level of .025, adding 10% for participant dropout and protocol violations. Participants received either 12 mL of a 1% lidocaine paracervical block or 20 mL of a self-administered, 2% lidocaine gel 20-30 minutes before procedure initiation. Secondary outcomes included anticipated pain, baseline pain, pain with speculum and tenaculum placement, pain after suction aspiration, and pain 30-45 minutes postoperatively.From April to October 2015, a total of 142 women were enrolled (68 in the paracervical block group, 69 in the gel group, and five not analyzed as a result of participant withdrawal). Sociodemographic characteristics were similar between groups. The mean pain score with cervical dilation was 60 mm (95% confidence interval [CI] 54-66) in the paracervical block group and 64 mm (95% CI 59-69) in the gel group (P=.3). There was no significant difference between mean pain scores at any time points measured.Self-administration of lidocaine gel before first-trimester surgical abortion is noninferior to a traditional paracervical lidocaine block and should be considered as an alternative, noninvasive approach to pain control for first-trimester surgical,, NCT02447029.

View details for DOI 10.1097/AOG.0000000000001532

View details for PubMedID 27400015

Adjunct mifepristone for cervical preparation prior to dilation and evacuation: a randomized trial CONTRACEPTION Shaw, K. A., Shaw, J. G., Hugin, M., Velasquez, G., Hopkins, F. W., Blumenthal, P. D. 2015; 91 (4): 313-319


The objective was to investigate mifepristone as a potential adjunct to cervical preparation for surgical abortion after 19weeks of gestation, with the aim of improving procedure access, convenience and comfort.This is a site-stratified, block-randomized, noninferiority trial of 50 women undergoing surgical abortion between 19 and 23 6/7weeks of gestation randomized to receive either one set of osmotic dilators plus mifepristone the day prior to procedure (mifepristone group) or two sets of osmotic dilators (placed 18-24 h apart) in the 2 days prior to procedure (control group). All subjects received preprocedure misoprostol. Primary outcome was procedure time. Secondary outcomes included preoperative cervical dilation, ease of procedure, and side effects and pain experienced by subjects.Mean gestational age was similar between groups (20weeks); more nulliparous subjects were randomized to the mifepristone group (46% vs. 12%, p=.009). Mean procedure times were similar: mifepristone group 11:52 (SD 5:29) vs. control group 10:56 (SD 5:08); difference in means -56s, with confidence interval (95% CI -4:09 to +2:16) not exceeding the 5-min difference we a priori defined as clinically significant. Preprocedure cervical dilation did not differ and was >3cm for the majority of subjects in both groups. There was no difference (p=.6) in ease of procedure reported by providers. Preoperative (postmisoprostol) pain and postoperative pain levels were greater with mifepristone (p = 0.02 and p= 0.04 respectively). Overall subject experience was not different (p=0.80), with most reporting a "better than expected" experience.Mifepristone with one set of osmotic dilators and misoprostol did not result in longer procedure times or less cervical dilation than serial (two sets) of osmotic dilators and misoprostol, and has the potential to improve access to second trimester abortion without compromising safety.Use of mifepristone for cervical preparation before surgical abortion after 19weeks allows for fewer visits and fewer osmotic dilators without compromising cervical dilation or increasing procedure time.

View details for DOI 10.1016/j.contraception.2014.11.014

View details for Web of Science ID 000351190700009

View details for PubMedID 25499589

Posttraumatic Stress Disorder and Risk of Spontaneous Preterm Birth OBSTETRICS AND GYNECOLOGY Shaw, J. G., Asch, S. M., Kimerling, R., Frayne, S. M., Shaw, K. A., Phibbs, C. S. 2014; 124 (6): 1111-1119


To evaluate the association between antenatal posttraumatic stress disorder (PTSD) and spontaneous preterm delivery.We identified antenatal PTSD status and spontaneous preterm delivery in a retrospective cohort of 16,334 deliveries covered by the Veterans Health Administration from 2000 to 2012. We divided mothers with PTSD into those with diagnoses present the year before delivery (active PTSD) and those only with earlier diagnoses (historical PTSD). We identified spontaneous preterm birth and potential confounders including age, race, military deployment, twins, hypertension, substance use, depression, and results of military sexual trauma screening and then performed multivariate regression to estimate adjusted odds ratio (OR) of spontaneous preterm delivery as a function of PTSD status.Of 16,334 births, 3,049 (19%) were to mothers with PTSD diagnoses, of whom 1,921 (12%) had active PTSD. Spontaneous preterm delivery was higher in those with active PTSD (9.2%, n=176) than those with historical (8.0%, n=90) or no PTSD (7.4%, n=982) before adjustment (P=.02). The association between PTSD and preterm birth persisted, when adjusting for covariates, only in those with active PTSD (adjusted OR 1.35, 95% confidence interval [CI] 1.14-1.61). Analyses adjusting for comorbid psychiatric and medical diagnoses revealed the association with active PTSD to be robust.In this cohort, containing an unprecedented number of PTSD-affected pregnancies, mothers with active PTSD were significantly more likely to suffer spontaneous preterm birth with an attributable two excess preterm births per 100 deliveries (95% CI 1-4). Posttraumatic stress disorder's health effects may extend, through birth outcomes, into the next generation.

View details for DOI 10.1097/AOG.0000000000000542

View details for Web of Science ID 000345341100008

Mifepristone-Misoprostol Dosing Interval and Effect on Induction Abortion Times A Systematic Review OBSTETRICS AND GYNECOLOGY Shaw, K. A., Topp, N. J., Shaw, J. G., Blumenthal, P. D. 2013; 121 (6): 1335-1347


To examine the effect of the interval between mifepristone and misoprostol administration on induction time (first misoprostol dose to abortion), total procedure time (mifepristone administration to abortion), and safety and efficacy in second-trimester induction abortion (13-24 weeks).We searched MEDLINE (1966-2012),, POPLINE, and the Cochrane Controlled Trials Register using search terms for second trimester, abortion, misoprostol, and mifepristone and reviewed reference lists of published reports.Our search revealed 138 articles of which 29 met inclusion criteria: 20 randomized controlled trials and nine observational studies. Studies were included if, in any study arm, mifepristone and misoprostol were used for medical abortion in the second trimester.Two authors independently reviewed the articles and abstracted the data using standardized data abstraction templates to summarize data. Discrepancies were resolved by consensus. Three studies directly compared a 1-day to 2-day mifepristone-misoprostol interval; they showed small differences in median induction times (weighted average 7.3 hours, range 7-8.5 for a 1-day interval; weighted average 6.8 hours, range 6.3-7.2 for a 2-day interval) and no significant difference in percent expelled by 12 hours or 24 hours. When all randomized studies using mifepristone and misoprostol were pooled by comparable mifepristone-misoprostol interval and misoprostol dose, induction times (first misoprostol dose to expulsion) were only 1-2 hours longer for a 12- to 24-hour interval compared with a 36-48-hour interval, whereas total abortion times (mifepristone to expulsion) were at least 18 hours longer in the 36- to 48-hour group. Induction times varied by misoprostol dosing, with 400-microgram misoprostol protocols resulting in shorter induction times than 200-microgram protocols.Shortening the mifepristone-misoprostol interval, thereby reducing total abortion time, does not compromise the safety or efficacy of second-trimester medication abortion and may be used to accommodate patient or health care provider preference.

View details for DOI 10.1097/AOG.0b013e3182932f37

View details for Web of Science ID 000319436100028

Prior Cesarean Birth and Risk of Uterine Rupture in Second-Trimester Medication Abortions Using Mifepristone and Misoprostol: A Systematic Review and Meta-analysis. Obstetrics and gynecology Henkel, A., Miller, H. E., Zhang, J., Lyell, D. J., Shaw, K. A. 2023


OBJECTIVE: To assess the risk difference of uterine rupture when using current mifepristone and misoprostol regimens for second-trimester abortion among individuals with prior cesarean birth compared with those without prior cesarean birth.DATA SOURCES: We searched the terms second trimester, induction, mifepristone, and abortion in PubMed, EMBASE, POPLINE,, and Cochrane Library from inception until December 2022.METHODS OF STUDY SELECTION: We included randomized trials and observational studies including a mixed cohort, with and without uterine scar, of individuals at 14-28 weeks of gestation who used mifepristone and misoprostol to end a pregnancy or to manage a fetal death. We excluded case reports, narrative reviews, and studies not published in English. Two reviewers independently screened studies.TABULATION, INTEGRATION, AND RESULTS: Absolute risks with binomial CIs were calculated from pooled data. Using R software, we estimated total risk difference by the Mantel-Haenszel random-effects method without continuity correction. For studies with zero events, a continuity correction of 0.5 was applied for individual risk differences and plotted graphically with forest plots. Statistical heterogeneity was assessed with Higgins I2 statistics. Funnel plot assessed for publication bias. Of 198 articles identified, 22 met the inclusion criteria: seven randomized trials (n=923) and 15 observational studies (n=6,195). Uterine rupture risk with prior cesarean birth was 1.1% (10/874) (95% CI 0.6-2.1) and without prior cesarean birth was 0.01% (2/6,244) (95% CI 0.0-0.12). The risk difference was 1.23% (95% CI 0.46-2.00, I2=0%). Of the 12 reported uterine ruptures, three resulted in hysterectomy.CONCLUSION: Uterine rupture with mifepristone and misoprostol use during second-trimester induction abortion is rare, with the risk increased to 1% in individuals with prior cesarean birth.SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022302626.

View details for DOI 10.1097/AOG.0000000000005259

View details for PubMedID 37884011

The Experience of Breast Symptoms after Second-Trimester Abortion or Pregnancy Loss. American journal of obstetrics and gynecology Henkel, A., Reeves, M. F., Shaw, K. A. 2023

View details for DOI 10.1016/j.ajog.2023.10.025

View details for PubMedID 37863161

Cervical preparation for second-trimester procedural abortion. Current opinion in obstetrics & gynecology Fraz, F., Liu, S. M., Shaw, K. A. 2023


To review the evidence-informed options for cervical preparation prior to second-trimester dilation and evacuation (D&E).As abortion restrictions increase and the number of abortion clinics and providers decreases, pregnant people are facing more barriers to abortion access. Those in need are now often required to travel for second-trimester abortion care, only to be faced with additional restrictions, such as mandatory waiting periods. Cervical preparation is recommended prior to D&E and takes time for effect. Given the increasing time required to obtain an abortion, patients and providers may prefer same-day cervical preparation to decrease the total time required. Options for same-day cervical preparation include misoprostol alone with single or serial doses, and misoprostol combined with osmotic dilators or transcervical balloon (Foley catheter). Same-day preparation may require additional clinical space to accommodate people after initiation of cervical preparation to manage side-effects and timing of the abortion. Overnight options are also used and more frequently later in the second trimester. Overnight options include mifepristone, osmotic dilators, and transcervical balloon and are often combined with same-day misoprostol. Medication alone preparation is well tolerated and effective in the second trimester, with the addition of mechanical methods with advancing gestation. With many options and combinations being safe and effective, providers can be dynamic and alter approach with supply shortages, adjust to different clinical settings, consider patient medical and surgical factors, and accommodate provider and patient preferences.Multiple pharmacologic and mechanical options have been shown to be safe and effective for cervical preparation prior to D&E. Consideration for multiple factors should influence the method of cervical preparation and methods may vary by patient, provider and setting.

View details for DOI 10.1097/GCO.0000000000000912

View details for PubMedID 37678155

Postpartum long-acting reversible contraceptive use among active-duty, female U.S. Army soldiers. American journal of obstetrics and gynecology Eastin, E. F., Nelson, D. A., Shaw, J. G., Shaw, K. A., Kurina, L. M. 2023


BACKGROUND: Postpartum utilization of long-acting reversible contraception (LARC) has been found to be effective at increasing inter-pregnancy intervals, reducing unintended pregnancies, and optimizing health outcomes for mothers and babies. Among female active-duty military members, reproductive planning may be particularly important, yet little is known about postpartum long-acting reversible contraceptive use among active-duty soldiers.OBJECTIVES: (1) To quantify postpartum uptake of long-acting reversible contraception among U.S. Army active-duty female soldiers, and (2) to identify demographic and military-specific characteristics associated with utilization.STUDY DESIGN: This retrospective cohort study used longitudinal data on all digitally recorded health encounters for active-duty U.S. Army soldiers from 2014-2017. The servicewomen included in our analysis were aged 18-44 years with at least one delivery and a minimum of four months of total observed time post-delivery within the study period. We defined postpartum long-acting reversible contraception utilization as initiation in the delivery month or in the three calendar months following delivery, and identified likely immediate postpartum initiation via the proxy of placement recorded during the same month as delivery. We then evaluated predictors of postpartum long-acting reversible contraception utilization using multivariable logistic regression.RESULTS: Inclusion criteria were met by 15,843 soldiers. Of those, 3,162 (19.96%) received a method of long-acting reversible contraception in the month of, or within the three months following, delivery. Fewer than 5% of these women utilized immediate postpartum long-acting reversible contraception. Among women receiving a postpartum long-acting reversible contraceptive method, 1,803 (57.0%) received an IUD, 1,328 (42.0%) received an etonogestrel implant and 31 received both (0.98%). Soldiers of younger age, self-reported White race, and those married or previously married were more likely to initiate long-acting reversible contraception in the postpartum period. Race-stratified analyses showed that self-reported White women had the highest utilization rates overall. Compared to these women, the adjusted odds of postpartum utilization among self-reported Black and Asian/Pacific Islander women were 18% and 30% lower, respectively (both p<0.001). There was also a trend of decreasing postpartum utilization with increasing age within each race group. Differences observed between age groups and race identities could partially be attributed to differential utilization of permanent contraception (sterilization), which was found to be significantly more prevalent among both women aged 30 years or older, as well as among Black-identifying women.CONCLUSION: Among active-duty U.S. Army servicewomen, one in five utilized postpartum long-acting reversible contraception, with fewer than 5 percent of these women utilizing an immediate postpartum method. Within this population with universal healthcare coverage, we observed relatively low rates of utilization and significant differences in uptake of effective postpartum long-acting contraceptive methods across self-reported race categories.

View details for DOI 10.1016/j.ajog.2023.07.023

View details for PubMedID 37460035

Postpartum long-acting reversible contraception among privately insured: national analysis 2007-2016, by term and preterm birth. Contraception Shaw, J. G., Goldthwaite, L. M., Mari, I., Shaw, K. A., Stevenson, D. K., Shaw, G. M. 2023: 110065


To investigate postpartum long-acting reversible contraception (LARC) use among privately insured women, with specific consideration of use after preterm delivery.We used the national IBM MarketScan Commercial Database to identify singleton deliveries from 2007-2016, spontaneous preterm birth, and follow up 12 weeks postpartum. We assessed 12 week postpartum LARC placement overall and after spontaneous preterm deliveries, across study years. We examined timing of placement, rates of postpartum follow-up, and state-level variation in postpartum LARC.Among 3,132,107 singleton deliveries, 6.6% were spontaneous preterm. Over the time period, total postpartum LARC use increased: 4.8% to 11.7% for intrauterine devices (IUDs), 0.2% to 2.4% for implants. In 2016, those who experienced a spontaneous preterm birth were less likely to initiate postpartum IUDs compared to their peers (10.2% vs 11.8%, p<0.001), minimally more likely to initiate implants (2.7% vs 2.4%, p=0.04) and more likely to present for postpartum care (61.7% vs 55.9%, p<0.001). LARC placement prior to hospital discharge was rare (preterm: 8 per 10,000 deliveries vs all others: 6.3 per 10,000 deliveries, p=0.002). State level analysis showed wide variation in postpartum LARC (range 6%-32%).While postpartum LARC use increased among the privately insured 2007 to 2016, few received LARC prior to hospital discharge. Those experiencing preterm birth were no more likely to receive inpatient LARC. Postpartum follow-up remained low and regional variation of LARC was high, highlighting the need for efforts to remove barriers to inpatient postpartum LARC for all who desire it-public and privately insured alike.Among the half of U.S. births that are privately insured, postpartum LARC is increasing after both term and preterm births, yet exceedingly few (<0.1%) received LARC prior to hospital discharge.

View details for DOI 10.1016/j.contraception.2023.110065

View details for PubMedID 37210023

Anesthetic Considerations for Second-Trimester Surgical Abortions. Anesthesia and analgesia Ozery, E., Ansari, J., Kaur, S., Shaw, K. A., Henkel, A. 2022


Although most abortion care takes place in the office setting, anesthesiologists are often asked to provide anesthesia for the 1% of abortions that take place later, in the second trimester. Changes in federal and state regulations surrounding abortion services may result in an increase in second-trimester abortions due to barriers to accessing care. The need for interstate travel will reduce access and delay care for everyone, given limited appointment capacity in states that continue to support bodily autonomy. Therefore, anesthesiologists may be increasingly involved in care for these patients. There are multiple, unique anesthetic considerations to provide safe and compassionate care to patients undergoing second-trimester abortion. First, a multiday cervical preparation involving cervical osmotic dilators and pharmacologic agents results in a time-sensitive, nonelective procedure, which should not be delayed or canceled due to risk of fetal expulsion in the preoperative area. In addition, a growing body of literature suggests that the older anesthesia dogma that all pregnant patients require rapid-sequence induction and an endotracheal tube can be abandoned, and that deep sedation without intubation is safe and often preferable for this patient population through 24 weeks of gestation. Finally, concomitant substance use disorders, preoperative pain from cervical preparation, and intraoperative management of uterine atony in a uterus that does not yet have mature oxytocin receptors require additional consideration.

View details for DOI 10.1213/ANE.0000000000006321

View details for PubMedID 36729414

Paging the Clinical Informatics Community: Respond STAT to Dobbs v Jackson's Women's Health Organization. Applied clinical informatics Arvisais-Anhalt, S., Ravi, A., Weia, B., Aarts, J., Ahmad, H. B., Araj, E., Bauml, J. A., Benham-Hutchins, M., Boyd, A. D., Brecht-Doscher, A., Butler-Henderson, K., Butte, A., Cardillo, A. B., Chilukuri, N., Cho, M. K., Cohen, J. K., Craven, C. K., Crusco, S. J., Dadabhoy, F., Dash, D., DeBolt, C., Elkin, P. L., Fayanju, O. A., Fochtmann, L., Graham, J. V., Hanna, J., Hersh, W., Hoffard, M. R., Hron, J., Huang, S. S., Jackson, B. R., Kaplan, B., Kelly, W., Ko, K., Koppel, R., Kurapati, N., Labbad, G., Lee, J., Lehmann, C. U., Leitner, S., Liao, Z. C., Medford, R. J., Melnick, E. R., Muniyappa, A. N., Murray, S., Neinstein, A., Nichols-Johnson, V., Novak, L., Ogan, W. S., Ozeran, L., Pageler, N., Pandita, D., Perumbeti, A., Petersen, C., Pierce, L., Puttagunta, R., Ramaswamy, P., Rogers, K. M., Rosenbloom, T., Ryan, A., Saleh, S., Sarabu, C., Schreiber, R., Shaw, K. A., Sim, I., Sirintrapun, S. J., Solomonides, A., Spector, J. D., Starren, J. B., Stoffel, M., Subbian, V., Swanson, K., Tomes, A., Trang, K., Unertl, K. M., Weon, J. L., Whooley, M., Wiley, K., Williamson, D. F., Winkelstein, P., Wong, J., Xie, J., Yarahuan, J. K., Yung, N., Zera, C., Ratanawongsa, N., Sadasivaiah, S. 2022



View details for DOI 10.1055/a-2000-7590

View details for PubMedID 36535703

Addressing postpartum contraception practices utilizing a multidisciplinary Pregnancy Heart Team approach. AJOG global reports Miller, H. E., Do, S. C., Cruz, G., Panelli, D. M., Leonard, S. A., Girsen, A., Lee, C. J., Khandelwal, A., Shaw, K. A., Bianco, K. 2022; 2 (4): 100100


BACKGROUND: Cardiovascular disease has emerged as the leading cause of maternal morbidity and mortality, making planned pregnancy, and thereby reliable contraception among people with cardiovascular disease, vital.OBJECTIVE: This study aimed to compare postpartum contraceptive practices among people with cardiovascular disease (cardiac cohort) cared for by a Pregnancy Heart Team to people with other chronic comorbidities (high-risk cohort), and people without comorbidities (low-risk cohort). We hypothesized that the Pregnancy Heart Team influenced baseline contraception counseling and practices among those with cardiovascular disease.STUDY DESIGN: This was a retrospective cohort study comparing postpartum contraceptive practices between a cardiac cohort who received care by a multidisciplinary team between 2012 and 2020 and high-risk and low-risk cohorts delivering at a single academic center between 2016 and 2019. We investigated presence of a contraceptive plan (at birthing admission, discharge, and postpartum visit) and uptake of reliable contraception by 8 weeks postpartum.RESULTS: We included 1464 people: 189 with cardiovascular disease, 197 with other chronic comorbidities, and 1078 low-risk people. At birth hospitalization admission, reliable contraception was planned among 42% of the cardiac cohort, 40% of the high-risk cohort, and 31% of the low-risk cohort, with similar distributions at the time of discharge and at 8 weeks postpartum.Compared with the cardiac cohort, by 8 weeks postpartum,the high-risk cohort had similar odds of using highly reliable forms of contraception (39% vs 36%; adjusted odds ratio, 0.78; 95% confidence interval, 0.50-1.21) and similar odds of having a plan to use the most reliable forms of contraception (intrauterine device, implant, bilateral tubal ligation) at the time of birthing admission (42% vs 40%; adjusted odds ratio, 0.78; 95% confidence interval, 0.50-1.22), discharge (47% vs 45%; adjusted odds ratio, 0.95; 95% confidence interval, 0.61-1.48), and postpartum visit (35% vs 29%; adjusted odds ratio, 0.76; 95% confidence interval, 0.49-1.17).The low-risk cohort had lower odds of using a reliable form of contraception (39% vs 27%; adjusted odds ratio, 0.53; 95% confidence interval, 0.37-0.75) and was less likely to have a plan for reliable contraception at the time of birthing admission (42% vs 31%; adjusted odds ratio, 0.54; 95% confidence interval, 0.38-0.76), discharge (47% vs 33%; adjusted odds ratio, 0.58; 95% confidence interval, 0.4-0.82), and postpartum visit (35% vs 21%; adjusted odds ratio, 0.50; 95% confidence interval, 0.35-0.71).CONCLUSION: People with cardiovascular disease cared for by a Pregnancy Heart Team had higher odds of reliable postpartum contraception planning and uptake compared with a low-risk cohort and similar odds compared with a high-risk cohort. Pregnancy could serve as a critical period for contraception counseling and family planning among people with cardiovascular disease. A multidisciplinary team should be used to address postpartum contraception as a modifiable risk factor to reduce maternal morbidity and mortality among those with cardiovascular disease.

View details for DOI 10.1016/j.xagr.2022.100100

View details for PubMedID 36536840

Cervical Preparation Using Ulipristal Acetate With Adjunct Misoprostol in Second-Trimester Surgical Abortions. Obstetrics and gynecology Peterson, S. F., Lerma, K., Shaw, K. A., Blumenthal, P. D. 2022; 139 (5): 907-909

View details for DOI 10.1097/AOG.0000000000004754

View details for PubMedID 35576349

Potential candidate for oral pericoital contraception: evaluating ulipristal acetate plus cyclo-oxygenase-2 inhibitor for ovulation disruption. BMJ sexual & reproductive health Cahill, E. P., Lerma, K., Shaw, K. A., Blumenthal, P. D. 2022


BACKGROUND: There remains considerable global unmet contraceptive need, with almost 200million women reporting desire to limit or space childbearing without contraceptive use. Researchers have documented worldwide interest in an oral, on-demand contraceptive option were it available. Candidates for use include ulipristal acetate (UA), levonorgestrel and cyclo-oxygenase-2 (COX-2) inhibitors alone or in combination.METHODS: We performed an exploratory, prospective study of matched menstrual cycles: one baseline cycle and one treatment cycle of UA 30mg plus meloxicam 30mg just prior to ovulation. The primary outcome was ovulation disruption, defined as unruptured dominant follicle for 5days. Secondary outcomes included comparing cycle length, endometrial stripe thickness, and side effects.RESULTS: Nine participants completed all study procedures in both cycles. Ovulatory disruption occurred in 66.7% (n=6) of treatment cycles and all but one demonstrated features of ovulatory dysfunction. Cycle length (meanSD) was longer in the treatment cycle (31.94.0 vs 28.63.5 days, p<0.01). Secondary outcomes did not differ between the two cycles.CONCLUSIONS: UA plus the COX-2 inhibitor meloxicam disrupts ovulation at peak luteal surge and is a promising candidate for evaluation as a pericoital oral contraceptive.TRIAL REGISTRATION NUMBER: NCT03354117.

View details for DOI 10.1136/bmjsrh-2021-201446

View details for PubMedID 35470225

Pain management in outpatient surgical abortion. Current opinion in obstetrics & gynecology Liu, S. M., Shaw, K. A. 2021; 33 (6): 440-444


PURPOSE OF REVIEW: To review the current literature focusing on pain management and experiences during abortion care.RECENT FINDINGS: Analgesic options in abortion care address pain associated with the procedure, osmotic dilator insertion, and cervical preparation. The paracervical block (PCB) is effective for pain control in first and second trimester abortions. Lower volume PCBs demonstrate non inferiority with osmotic dilator placement compared with higher volume PCBs with lower potential for toxicity. Self-administered vaginal lidocaine gel is noninferior to PCB in first trimester abortions. Preoperative oral narcotics and sedation do not reduce pain in first trimester abortions; however, the latter may reduce anxiety. For second trimester abortions, narcotics or gabapentin do not improve postoperative pain, yet up to half of patients will use narcotics if offered. Nonpharmacological methods have shown success in pain management. Music and doula support do not improve pain; however, patients would recommend these modalities, indicating some benefit that went unmeasured. Auricular acupuncture and transcutaneous electrical nerve stimulation (TENS) reduce pain and anxiety during first trimester abortions.SUMMARY: Several modalities reduce pain during abortion care; however, pain alone does not reflect patient satisfaction. Development of multidimensional measures for pain control assessment has the potential to capture the patient's overall experience.

View details for DOI 10.1097/GCO.0000000000000754

View details for PubMedID 34747880

Making the financial case for immediate postpartum intrauterine device: a budget impact analysis. American journal of obstetrics and gynecology Fitzgerald, A. C., Shaw, J. G., Shaw, K. A. 2021


BACKGROUND: Clinical guidelines support inpatient postpartum intrauterine device insertion; however, inpatient placement remains infrequent, in part due to inconsistent private insurance reimbursement.OBJECTIVE: The purpose of this study was to explore how the payer's costs and number of unintended pregnancies associated with postpartum intrauterine device differed on the basis of placement timing.STUDY DESIGN: Using a decision tree model, following a hypothetical cohort of people who intend to use an intrauterine device after their delivery, we conducted a cost analysis comparing planned approach of inpatient versus outpatient postpartum insertion. Using a two-year time horizon, probability and cost estimates were derived from literature review. Our primary outcome was total accrued costs to the payer. Secondarily, we examined rates of early repeat pregnancy, and sensitivity to estimates of key inputs including expulsion rates and intrauterine device cost.RESULTS: While inpatient intrauterine device placement's up-front costs were higher, total cost of this approach was lower. Including costs of managing expulsions and complications, our model suggests that for every 1000 people desiring postpartum intrauterine device, intended inpatient intrauterine device placement resulted in a total cost savings of $211,100 and prevention of 37 additional pregnancies as compared to outpatient placement. Inpatient cost savings were superior to outpatient largely due to a known high proportion not returning for outpatient placement, and the resulting higher number of unintended pregnancies among patients desiring outpatient placement. In sensitivity analyses, we found that total cost to the payer was sensitive to the probability of expulsion after immediate postpartum intrauterine device placement.CONCLUSIONS: For beneficiaries desiring postpartum intrauterine device, payers are likely to save money by fully reimbursing inpatient intrauterine device placement rather than incentivizing placement at the frequently missed postpartum visit. These results support the financial case for private insurers to fully and separately reimburse (i.e. "unbundle" from the single payment for delivery) inpatient postpartum intrauterine device placement.

View details for DOI 10.1016/j.ajog.2021.11.1348

View details for PubMedID 34801445

First Trimester Abortion Care in Low- and Middle-Income Countries. Clinical obstetrics and gynecology Henkel, A., Shaw, K. A. 2021; 64 (3): 449-459


Access to first trimester abortions has increased significantly in the past few decades in low and middle-income countries. Manual vacuum aspiration is now standard of care for procedural abortion and postabortion care. Medication abortion has shifted abortions to being performed earlier in pregnancy and is becoming more widely available with new service delivery strategies to broaden access. Widespread availability of misoprostol has made abortions induced outside of the formal medical sector overall safer. In both legally restrictive and supportive environments, there is increased interested in self-managed abortions as part of a shift towards demedicalizing abortion through task-sharing.

View details for DOI 10.1097/GRF.0000000000000626

View details for PubMedID 34323227

The impact of the COVID-19 pandemic on postpartum contraception planning AMERICAN JOURNAL OF OBSTETRICS & GYNECOLOGY MFM Miller, H. E., Henkel, A., Leonard, S. A., Miller, S. E., Tran, L., Bianco, K., Shaw, K. A. 2021; 3 (5)
Comparison of Two Home Pregnancy Tests for Self-Confirmation of Medication Abortion Status: A Randomized Trial. Contraception Fok, W. K., Lerma, K., Shaw, K. A., Blumenthal, P. D. 2021


OBJECTIVES: To evaluate individuals' ability to perform and comprehend low-sensitivity and multilevel urine pregnancy tests during medication abortion follow-up.STUDY DESIGN: We conducted a pilot study of individuals using mifepristone and misoprostol for medication abortion through 63-days gestation. We randomly assigned participants to use a 1000 mIU/mL low-sensitivity pregnancy test or a five-level multilevel pregnancy test. Seven days after mifepristone, participants performed their test and completed a questionnaire. One week later, participants performed another test if day 7 low-sensitivity test had been positive or day 7 multilevel test had not shown a one-level drop. We assessed comprehension of abortion status based on participants' final test interpretation, and defined correct comprehension when patient report of pregnancy status was consistent with pregnancy test result. We also assessed usability with a 100-mm Visual Analogue Scale (0 'very easy'; 100 'very difficult') and satisfaction.RESULTS: We enrolled and randomized 88 participants to low-sensitivity (n=43) and multilevel (n=45) test groups. Comprehension was correct in 38/39 (97%) and 41/45 (91%) of low-sensitivity and multilevel test users, respectively (p=0.37). When the test indicated a possible ongoing pregnancy, all three low-sensitivity test users and two of three multilevel test users accurately comprehended their results. Participants rated ease of use as 7.5 (range 0-68) for low-sensitivity and 9.0 (range 0-52) for multilevel (p=0.24) tests. Most participants were likely or very likely to recommend use of their test (32/36 [89%] low-sensitivity and 42/44 [95%] multilevel test users, p=0.66).CONCLUSIONS: Patients could comprehend and use low-sensitivity and multilevel tests during medication abortion follow-up with similar satisfaction.IMPLICATIONS: Individuals are able to independently use both the low-sensitivity and multilevel tests for medication abortion follow-up. Both are acceptable for medication abortion follow-up without in-person contact, but future, larger studies to compare comprehension of both tests may be necessary.

View details for DOI 10.1016/j.contraception.2021.05.003

View details for PubMedID 33992610

Dysmenorrhoea as a risk factor for pain with intrauterine device insertion. BMJ sexual & reproductive health Schneyer, R., Lerma, K., Conti, J., Shaw, K. 2021


BACKGROUND: Understanding predictors of pain with gynaecological procedures may facilitate individualised counselling and pain management. We aimed to study the effect of dysmenorrhoea on intrauterine device (IUD) insertion pain.METHODS: This was a planned secondary analysis of a randomised trial evaluating self-administered lidocaine gel versus placebo for IUD insertion pain. We included those participants who reported menses in the past 3months. We assessed dysmenorrhoea (in the past 3months) and procedural pain using a 100mm visual analogue scale (VAS). We categorised dysmenorrhoea as none/mild (<40mm), moderate (40-69mm) or severe (70mm). We assessed participant pain scores at speculum insertion, tenaculum placement, IUD insertion, and overall. We compared median procedural pain scores by dysmenorrhoea group with three-way and post hoc pairwise analyses.RESULTS: We analysed 188 participants. Demographic characteristics were similar among the three dysmenorrhoea groups. Pairwise comparisons revealed higher median procedural pain scores in the severe dysmenorrhoea group compared with the none/mild dysmenorrhoea group at speculum insertion (25mm vs 8mm; p=0.007), tenaculum placement (51mm vs 31mm; p=0.04) and IUD insertion (74mm vs 61mm; p=0.04). Overall pain did not differ among the three groups (p=0.32).CONCLUSIONS: Patients with severe dysmenorrhoea experienced increased pain with all aspects of IUD insertion, including speculum and tenaculum placement, compared with those with only mild or no dysmenorrhoea. Clinicians may consider this finding when providing individualised counselling and pain management for patients undergoing IUD insertion and other gynaecological procedures. Larger studies are needed to validate the effect of dysmenorrhoea severity on pain throughout IUD insertion.

View details for DOI 10.1136/bmjsrh-2020-200918

View details for PubMedID 33789955

The impact of the COVID-19 pandemic on postpartum contraception planning. American journal of obstetrics & gynecology MFM Miller, H. E., Henkel, A., Leonard, S. A., Miller, S. E., Tran, L., Bianco, K., Shaw, K. A. 2021: 100412

View details for DOI 10.1016/j.ajogmf.2021.100412

View details for PubMedID 34058421

Socioeconomic Differences Persist in Use of Permanent versus Long-Acting Reversible Contraception: An Analysis of the National Survey for Family Growth, 2006-2010 versus 2015-2017. Contraception Beshar, I., So, J., Chelvakumar, M., Cahill, E. P., Shaw, K. A., Shaw, J. G. 2020


OBJECTIVE: Permanent contraception has historically been more prevalent among non-White women with lower education and income. Given increasing popularity of long-acting reversible contraception (LARC), we examine changing sociodemographic patterns of permanent contraception and LARC.STUDY DESIGN: We performed a descriptive analysis of the National Survey of Family Growth (NSFG) from 2006-2017, with multivariable analyses of the 2006-2010 and 2015-2017 cohorts. Using multinomial logistic regression, we investigate predictors of contraceptive category (permanent contraception versus LARC, lower-efficacy contraception versus LARC) in reproductive-aged women.RESULTS: 8,161 respondents were included in two distinct but analogous regression analyses: 1) the most recent survey cohort, 2015-2017, and 2) the cohort a decade prior, 2006-2010. Over this period, the prevalence of LARC increased nearly three-fold (6.2% to 16.7%), while permanent contraception use trended downwards (22% to 18.6%). Yet, in adjusted models, we observed little change in the sociodemographic predictors of permanent contraception: from the early to recent cohort, use of permanent contraception (versus LARC) remained less likely among college graduates (multinomial odds ratio (OR) 0.45[95% CI 0.21, 0.97]) and Hispanic women (OR 0.41[0.21, 0.82]). In addition, high income (>$74,999) and metropolitan residence came to predict less use (OR 0.33[0.13, 0.84] and 0.47[0.23, 0.97]). Multiparity, advanced age (over 35), and marital status remained strong predictors of permanent contraception.CONCLUSION: Although use of LARC nearly equals that of permanent contraception in the most recent NSFG survey, socioeconomic differences persist. Continued effort is needed to detect and address structural barriers to accessing the most effective forms of contraception for women.IMPLICATIONS: Comparing 2006-2010 to 2015-2017, reliance on female permanent contraception decreased while LARC use increased, making prevalence more similar. However, significant socioeconomic differences persist in who chooses permanent contraception, with urban, educated, higher-income women more likely to use LARC. Ongoing efforts are needed to understand and reduce economic barriers to LARC.

View details for DOI 10.1016/j.contraception.2020.12.008

View details for PubMedID 33359509

Evaluation of shorter mifepristone to misoprostol intervals for second trimester medical abortion: a retrospective cohort study. Contraception Henkel, A., Lerma, K., Blumenthal, P. D., Shaw, K. A. 2020


OBJECTIVES: To assess shorter mifepristone-misoprostol intervals compared to current guidelines for second trimester medical abortion on total abortion time (mifepristone to fetal expulsion) and induction time (first misoprostol to fetal expulsion).METHODS: This retrospective cohort study included women who elected for a second trimester medical abortion with mifepristone and misoprostol at an academic tertiary medical center in the United States from January 2008 to June 2018. We abstracted times of mifepristone administration, first dose of misoprostol, and fetal expulsion from the medical record. We assessed outcomes based on the shorter intervals <12 hours and 12 to 24 hours compared to the guideline mifepristone-misoprostol interval (24-48 hours).RESULTS: The study population included eighty-nine women, 47, 28, and 14 women in the <12 hour, 12-24 hour, guideline (24-48 hour) groups, respectively. The cohort had a median gestational age of 220/7 weeks (range: 150/7-270/7) and parity of 1 (range: 0-5) with no differences observed between groups. Total abortion times were 20.7 hours (range: 3.7-46.9), 30.6 hours (16.7-48.0), and 42.8 hours (32.7-62.6), respectively (p<0.001). Induction times were 12.9 hours (range: 1.2-36.6), 11.7 hours (2.0-35.2), and 9.3 hours (5.3-16.5), respectively. Fetal expulsion within 12 hours of first misoprostol dose occurred in 22 (47%), 14 (50%), and 9 (64%), respectively (p=0.52).CONCLUSIONS: Shorter mifepristone-misoprostol intervals (less than 24 hours) significantly decrease the total abortion time while maintaining a clinically similar induction time.IMPLICATIONS: Shortening the mifepristone-misoprostol interval in second trimester medical abortion significantly decreases the total abortion time which may be preferable to some women or health systems. (Words: 25).

View details for DOI 10.1016/j.contraception.2020.06.009

View details for PubMedID 32592800

Postpartum LARC Among the Privately Insured-Use After Preterm and Term Births Goldthwaite, L., Maric, I., Shaw, K. A., Stevenson, D. K., Shaw, G. LIPPINCOTT WILLIAMS & WILKINS. 2020: 108S109S
Sociodemographic Trends in Long Acting Reversible Contraception vs. Female Sterilization, 2006-2017 Beshar, I. B., Chelvakumar, M., So, J., Cahill, E. P., Shaw, K. A., Shaw, J. G. LIPPINCOTT WILLIAMS & WILKINS. 2020: 100S
Uptake of Postpartum Long-Acting Reversible Contraception: The Impact of Timing and Practice Patterns Corbin, K., Miller, H., Bates, P., Lerma, K., Noon, B., Shaw, K. A. LIPPINCOTT WILLIAMS & WILKINS. 2020: 110S
Effect of Delivery Room Postpartum Contraceptive Implant Insertion on Initiation of Breastfeeding Shaw, K. A., Lerma, K., Reyes, G., Gutow, H., Shaw, J. G. LIPPINCOTT WILLIAMS & WILKINS. 2020: 105S
Induction of labor with an unfavorable cervix. Current opinion in obstetrics & gynecology Solone, M. n., Shaw, K. A. 2020


Recent evidence supports elective induction of labor after 39 weeks; however, labor induction in patients with an unfavorable cervix, a Bishop score less than 6, may take several days. In this review, we focus on the efficacy and safety of methods of labor induction for the unfavorable cervix.Recent evidence on the use of mechanical cervical preparation with transcervical balloons suggests balloons are the most effective option for decreasing time to delivery in the nulliparous patient. Single and double balloons are equally effective, with a volume of more 30ml being more effective. The addition of misoprostol or oxytocin concurrently with a balloon further expedites time to delivery.Mechanical dilation should be considered when available and technically possible for labor induction in patients with an unfavorable cervix. Misoprostol is an effective adjunct to trans-cervical balloons, further decreasing time to delivery as compared with balloon alone. When misoprostol is contraindicated, oxytocin is a safe, effective, alternative adjunct to trans-cervical balloons. More research is needed to evaluate safe outpatient options, induction methods in the setting of prior cesarean with an unfavorable cervix, and to directly compare misoprostol with oxytocin as adjuncts to transcervical balloons.

View details for DOI 10.1097/GCO.0000000000000608

View details for PubMedID 32004172

Trends in Postpartum Uptake of Long-Acting Reversible Contraception Between 2012 and 2016 Noon, B., Lerma, K., Kharsa, Z., Shaw, K. LIPPINCOTT WILLIAMS & WILKINS. 2019: 32S
Barriers to Completing Second-trimester Antenatal Screening: A Retrospective Cohort Study Beshar, I., Henkel, A., Cahill, E., Josh, Y., Shaw, K. LIPPINCOTT WILLIAMS & WILKINS. 2019: 25S
Improving contraceptive choice for military servicewomen: better provision serves both women and deployment planning BMJ SEXUAL & REPRODUCTIVE HEALTH Shaw, J. G., Shaw, K. A. 2019; 45 (2): 8687
Improving contraceptive choice for military servicewomen: better provision serves both women and deployment planning. BMJ sexual & reproductive health Shaw, J. G., Shaw, K. A. 2019; 45 (2): 8687

View details for PubMedID 31000570

Misoprostol as an Adjunct to Overnight Osmotic Dilators Prior to Second Trimester Dilation and Evacuation: A Systematic Review and Meta-Analysis. Contraception Cahill, E. P., Henkel, A. n., Shaw, J. G., Shaw, K. A. 2019


Misoprostol as an Adjunct to Overnight Osmotic Dilators Prior to Second Trimester Dilation and Evacuation: A Systematic Review and Meta-Analysis. Cahill EP, Henkel AG, Shaw JG, Shaw KA OBJECTIVE: To understand effect of adjunct misoprostol with overnight osmotic dilators for dilation and evacuation for cervical preparation after 16 weeks gestation on procedure time and dilation, complication rate, and side effects.We searched PubMed,, POPLINE, and the Cochrane Controlled Trials Register using search terms for second trimester, abortion, misoprostol, dilators and reviewed reference lists of published reports. Randomized controlled trials of cervical preparation for second trimester D&E using overnight osmotic dilators comparing adjunct misoprostol to placebo were included. Weighted mean and standard deviation (SD) and pooled binary outcomes were compared with two sample t-test or chi-square respectively.Among 84 articles identified, three met inclusion criteria of randomized controlled trials comparing adjunct misoprostol to placebo with overnight osmotic dilators prior to second trimester abortion with 457 total subjects at 16-24 weeks gestation (misoprostol n=228; placebo n=229). In the meta-analysis, misoprostol as compared to placebo did not significantly decrease mean procedure times (8.5 + 4.6 vs 9.6 + 5.8 minutes, p=0.78) or need for manual dilation (18% vs 28%, p=0.23). There was no difference in total complications (p=0.61), major complications (hemorrhage, uterine perforation, hospitalization, p=0.44), or cervical lacerations (p=0.87).Current limited evidence suggests that use of adjunctive misoprostol with osmotic dilators after 16 weeks does not affect procedure time or need for manual dilation. Further research is needed to determine if adjunctive misoprostol affects major complications and blood loss.Adjunctive misoprostol does not affect procedure time or need for manual dilation in mid to late second trimester abortion. Further research is needed to determine the effect of adjunctive misoprostol on major complications and blood loss.

View details for DOI 10.1016/j.contraception.2019.09.005

View details for PubMedID 31811840

Self-administered lidocaine gel for local anesthesia prior to osmotic dilator placement: a randomized trial. Contraception Schivone, G. B., Lerma, K., Montgomery, C., Wright, P., Conti, J. A., Blumenthal, P. D., Shaw, K. A. 2018


OBJECTIVE(S): To compare pain scores during cervical dilator placement prior to dilation and evacuation (D&E) with patient-administered vaginal lidocaine gel versus lidocaine paracervical block (PCB).STUDY DESIGN: We conducted an unblinded randomized trial of women18years of age undergoing surgical abortion at16weeks gestation in two outpatient clinics. We randomized participants to receive self-administered lidocaine gel 2% 20mL intravaginally 15-30min before procedure initiation, or lidocaine 1% 12mL PCB immediately prior to dilator placement. Participants rated their pain at various time points using a visual analog scale (VAS), including anticipated and baseline pain, speculum insertion, tenaculum placement, cervical dilator placement (primary outcome), and speculum removal.RESULTS: We enrolled 72 women and analyzed data for 69 participants. Socio-demographic characteristics and VAS scores at all time points, except for anticipated pain, were similar between groups. The median pain score with dilator placement was 48mm in the gel group and 61mm in the PCB group (p=.23). Procedure times the gel group and PCB group were 3.7min and 5.2min, respectively (p<.01). Lidocaine gel was non-inferior to PCB for reported pain scores (VAS) with dilator placement with a difference in means of-8mm (95% CI -21,5), favoring the gel.CONCLUSIONS: Self-administration of lidocaine gel prior to placement of cervical dilators for D&E is non-inferior to paracervical lidocaine block for local anesthesia and is a potential alternative to PCB for pain management with osmotic dilator placement.IMPLICATIONS: Lidocaine gel and similar products represent non-invasive, non-painful methods of local anesthesia for a variety of outpatient gynecologic procedures. Given our non-inferiority findings, if gel anesthetics are available they should be considered as an alternative to paracervical block.

View details for PubMedID 30500336

Advances in the management of early pregnancy loss. Current opinion in obstetrics & gynecology Henkel, A., Shaw, K. A. 2018


PURPOSE OF REVIEW: To describe recent advances in management of early pregnancy loss.RECENT FINDINGS: Addition of mifepristone to current protocols for medical management of miscarriage increases effectiveness of a single dose of misoprostol and significantly reduces subsequent aspiration procedures. Women with an incomplete evacuation after medical management may be treated expectantly with similar rates of complete expulsion compared with surgical management at 6 weeks. As cytogenetic analysis improves, analysis of products of conception can be performed whether collected after surgical or medical management and is an efficient strategy in starting a recurrent pregnancy loss work-up. For those seeking pregnancy after miscarriage, conception immediately following an early pregnancy loss is not associated with increased risk of subsequent miscarriage. However, recent studies suggest that the original intendedness of the pregnancy resulting in miscarriage does not predict future reproductive goals of the woman, so family planning should be discussed at the time of miscarriage.SUMMARY: Miscarriage is a common experience among reproductive-aged women and advances in medical management and modern-day aspiration techniques make the use of the sharp curette obsolete.

View details for PubMedID 30299321

Selection of Higher Risk Pregnancies into Veterans Health Administration Programs: Discoveries from Linked Department of Veterans Affairs and California Birth Data. Health services research Shaw, J. G., Joyce, V. R., Schmitt, S. K., Frayne, S. M., Shaw, K. A., Danielsen, B., Kimerling, R., Asch, S. M., Phibbs, C. S. 2018


OBJECTIVE: To describe variation in payer and outcomes in Veterans' births.DATA/SETTING: Secondary data analyses of deliveries in California, 2000-2012.STUDY DESIGN: We performed a retrospective, population-based study of all live births to Veterans (confirmed via U.S. Department of Veterans Affairs (VA) enrollment records), to identify payer and variations in outcomes among: (1) Veterans using VA coverage and (2) Veteran vs. all other births. We calculated odds ratios (aOR) adjusted for age, race, ethnicity, education, and obstetric demographics.METHODS: We anonymously linked VA administrative data for all female VA enrollees with California birth records.PRINCIPAL FINDINGS: From 2000 to 2012, we identified 17,495 births to Veterans. VA covered 8.6 percent (1,508), Medicaid 17.3 percent, and Private insurance 47.6 percent. Veterans who relied on VA health coverage had more preeclampsia (aOR 1.4, CI 1.0-1.8) and more cesarean births (aOR 1.2, CI 1.0-1.3), and, despite similar prematurity, trended toward more neonatal intensive care (NICU) admissions (aOR 1.2, CI 1.0-1.4) compared to Veterans using other (non-Medicaid) coverage. Overall, Veterans' birth outcomes (all-payer) mirrored California's birth outcomes, with the exception of excess NICU care (aOR 1.15, CI 1.1-1.2).CONCLUSIONS: VA covers a higher risk fraction of Veterans' births, justifying maternal care coordination and attention to the maternal-fetal impacts of Veterans' comorbidities.

View details for PubMedID 30198185

Deployment and Preterm Birth Among US Army Soldiers. American journal of epidemiology Shaw, J. G., Nelson, D. A., Shaw, K. A., Woolaway-Bickel, K., Phibbs, C. S., Kurina, L. M. 2018; 187 (4): 687-695


With increasing integration of women into combat roles in the US military, it is critical to determine whether deployment, which entails unique stressors and exposures, is associated with adverse reproductive outcomes. Few studies have examined whether deployment increases the risk of preterm birth; no studies (to our knowledge) have examined a recent cohort of servicewomen. We therefore used linked medical and administrative data from the Stanford Military Data Repository for all US Army soldiers with deliveries between 2011 and 2014 to estimate the associations of prior deployment, recency of deployment, and posttraumatic stress disorder with spontaneous preterm birth (SPB), adjusting for sociodemographic, military-service, and health-related factors. Of 12,877 deliveries, 6.1% were SPBs. The prevalence was doubled (11.7%) among soldiers who delivered within 6 months of their return from deployment. Multivariable discrete-time logistic regression models indicated that delivering within 6 months of return from deployment was strongly associated with SPB (adjusted odds ratio = 2.1, 95% confidence interval: 1.5, 2.9). Neither multiple past deployments nor posttraumatic stress disorder was significantly associated with SPB. Within this cohort, timing of pregnancy in relation to deployment was identified as a novel risk factor for SPB. Increased focus on servicewomen's pregnancy timing and predeployment access to reproductive counseling and effective contraception is warranted.

View details for DOI 10.1093/aje/kwy003

View details for PubMedID 29370332

View details for PubMedCentralID PMC5889029

Deployment and Preterm Birth Among United States Army Soldiers American Journal of Epidemiology Shaw, J. G., Nelson, D. A., Shaw, K. A., Woolaway-Bickel, K., Phibbs, C. S., Kurina, L. M. 2018: 68795


With increasing integration of women into combat roles in the US military, it is critical to determine whether deployment, which entails unique stressors and exposures, is associated with adverse reproductive outcomes. Few studies have examined whether deployment increases the risk of preterm birth; no studies (to our knowledge) have examined a recent cohort of servicewomen. We therefore used linked medical and administrative data from the Stanford Military Data Repository for all US Army soldiers with deliveries between 2011 and 2014 to estimate the associations of prior deployment, recency of deployment, and posttraumatic stress disorder with spontaneous preterm birth (SPB), adjusting for sociodemographic, military-service, and health-related factors. Of 12,877 deliveries, 6.1% were SPBs. The prevalence was doubled (11.7%) among soldiers who delivered within 6 months of their return from deployment. Multivariable discrete-time logistic regression models indicated that delivering within 6 months of return from deployment was strongly associated with SPB (adjusted odds ratio = 2.1, 95% confidence interval: 1.5, 2.9). Neither multiple past deployments nor posttraumatic stress disorder was significantly associated with SPB. Within this cohort, timing of pregnancy in relation to deployment was identified as a novel risk factor for SPB. Increased focus on servicewomen's pregnancy timing and predeployment access to reproductive counseling and effective contraception is warranted.

View details for DOI 10.1093/aje/kwy003

View details for PubMedCentralID PMC5889029

Update on second trimester medical abortion CURRENT OPINION IN OBSTETRICS & GYNECOLOGY Lerma, K., Shaw, K. A. 2017; 29 (6): 41318


To review recent literature on second trimester abortion with medical methods.Across studies published in the recent past, it is apparent that women prefer shorter procedures and procedure times. Several randomized controlled trials have confirmed adding mifepristone to the second trimester medication abortion regimen results in shorter abortion intervals from first misoprostol administration to complete fetal expulsion. A study of simultaneous administration of mifepristone and misoprostol yielded shorter mean 'total' abortion times, presenting several logistical advantages. Recent studies on the continuous dosing of misoprostol have produced critical evidence to support continued dosing until expulsion. These studies had a more practical design compared with previous protocols that capped the number of misoprostol doses.Second trimester surgical abortion is well tolerated and increasingly expeditious. Further research is needed to refine second trimester medical abortion methods, specific to the mifepristone, misoprostol dosing interval. A 12-hour mifepristone to misoprostol interval may be the optimal interval balancing patient preferences and logistical considerations. Pragmatic dosing, including continuous dosing of misoprostol, could yield results that better inform clinical guidelines and reduce burden on patient, provider, and health facility.

View details for PubMedID 28922193

Contraception in US servicewomen: emerging knowledge, considerations, and needs CURRENT OPINION IN OBSTETRICS & GYNECOLOGY Harrington, L. A., Shaw, K. A., Shaw, J. G. 2017; 29 (6): 43136


We describe current literature regarding contraceptive use among women serving in the military. We explore the state of contraceptive use by female servicewomen, gaps in knowledge, special considerations, and evidence of unmet needs.Recent data on US servicewomen show that overall rates of contraceptive use remain low. Data highlight disparities and suggest barriers to contraceptive uptake persist, with contraceptive use being lower around the time of deployment. Methods that do not require daily use or prescription refills, such as long-acting reversible contraception (LARC) - intrauterine devices and contraceptive implants - may be distinctly well suited for service and deployment. Two contemporary studies document growing popularity of LARC methods among female members of the military, possibly driven by a surge in contraceptive implant use. Nonetheless, LARC appears to remain underutilized.Despite no-cost provision, the importance of preventing unplanned pregnancy, and the potential benefits of cycle control during service, emerging data about the US military suggest barriers to and underutilization of contraception, particularly LARC. Research is needed to explore preferences and tailor contraceptive counseling to servicewomen. Existing and future work can inform efforts to standardize military provider training and ensure all servicewomen are appropriately counseled and have timely access to any method they may choose.

View details for PubMedID 28915159

Contraceptive counseling in reproductive-aged women treated for breast cancer at a tertiary care institution: a retrospective analysis CONTRACEPTION Johansen, S. L., Lerma, K., Shaw, K. A. 2017; 96 (4): 24853


The objective was to assess the frequency of documented contraceptive and fertility preservation counseling for women treated for breast cancer.We conducted a chart analysis of female breast cancer patients (n=211) ages 18-45 years receiving chemotherapy treatment at Stanford Comprehensive Cancer Center from 2010 to 2014. Primary outcomes of contraceptive counseling and fertility preservation counseling documentation were assessed for frequency. Secondary outcomes included pregnancy testing, contraception use and pregnancy during treatment.Among the total sample (n=211), sexual activity was documented in 24% of patients (n=51). Fifty-one percent (n=108) of patients received pregnancy testing prior to initiation of treatment. Past contraception use was documented in 74% of patients (n=156) and current contraception use in 25% (n=53). Twenty-six percent of patients received fertility preservation counseling alone (n=54), 10% received contraceptive counseling alone (n=22), and 12% received both types of counseling (n=25). Patients were three times more likely to receive contraceptive counseling if using contraception at diagnosis [odds ratio (OR) 3.1, confidence interval (CI) 1.1-9.1, p=.04], and older women were significantly less likely to receive counseling (OR 0.2, CI 0.1-1.0, p=.04). Two patients became pregnant and had an abortion during treatment (1%), and neither patient was using contraception nor received contraceptive or fertility preservation counseling.Documentation of fertility preservation counseling occurs more frequently than contraceptive counseling, but both occur suboptimally. Lack of documentation does not allow us to conclude that counseling did not occur, but it suggests the need to improve documentation and increase awareness of contraceptive needs and counseling.Women undergoing breast cancer treatment do not consistently receive counseling on contraception or fertility preservation as a part of their care. Efforts are needed to ensure that women treated for breast cancer routinely receive counseling about fertility preservation and contraceptive options.

View details for PubMedID 28645785

Post-traumatic Stress Disorder and Antepartum Complications: a Novel Risk Factor for Gestational Diabetes and Preeclampsia PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Shaw, J. G., Asch, S. M., Katon, J. G., Shaw, K. A., Kimerling, R., Frayne, S. M., Phibbs, C. S. 2017; 31 (3): 185-194


Prior work shows that Post-traumatic Stress Disorder (PTSD) predicts an increased risk of preterm birth, but the causal pathway(s) are uncertain. We evaluate the associations between PTSD and antepartum complications to explore how PTSD's pathophysiology impacts pregnancy.This retrospective cohort analysis of all Veterans Health Administration (VA)-covered deliveries from 2000-12 used the data of VA clinical and administration. Mothers with current PTSD were identified using the ICD-9 diagnostic codes (i.e. code present during the antepartum year), as were those with historical PTSD. Medical and administrative data were used to identify the relevant obstetric diagnoses, demographics and health, and military deployment history. We used Poisson regression with robust error variance to derive the adjusted relative risk estimates (RR) for the association of PTSD with five clinically relevant antepartum complications [gestational diabetes (GDM), preeclampsia, gestational hypertension, growth restriction, and abruption]. Secondary outcomes included proxies for obstetric complexity (repeat hospitalisation, prolonged delivery hospitalisation, and caesarean delivery).Of the 15 986 singleton deliveries, 2977 (19%) were in mothers with PTSD diagnoses (1880 (12%) current PTSD). Mothers with the complication GDM were 4.9% and those with preeclampsia were 4.6% of all births. After adjustment, a current PTSD diagnosis (reference = no PTSD) was associated with an increased risk of GDM (RR 1.4, 95% confidence interval (CI) 1.2, 1.7) and preeclampsia (RR 1.3, 95% CI 1.1, 1.6). PTSD also predicted prolonged (>4 day) delivery hospitalisation (RR 1.2, 95% CI 1.01, 1.4), and repeat hospitalisations (RR 1.4, 95% CI 1.2, 1.6), but not caesarean delivery.The observed association of PTSD with GDM and preeclampsia is consistent with our nascent understanding of PTSD as a disruptor of neuroendocrine and cardiovascular health.

View details for DOI 10.1111/ppe.12349

View details for Web of Science ID 000400170000004

View details for PubMedID 28328031

Contraceptive Practices of Women With Complex Congenital Heart Disease. American journal of cardiology Miner, P. D., Canobbio, M. M., Pearson, D. D., Schlater, M., Balon, Y., Junge, K. J., Bhatt, A., Barber, D., Nickolaus, M. J., Kovacs, A. H., Moons, P., Shaw, K., Fernandes, S. M. 2017; 119 (6): 911-915


Understanding the contraceptive practices of women with complex congenital heart disease (CHD) and providing them individualized contraception counseling may prevent adverse events and unplanned high-risk pregnancies. Given this, we sought to examine the contraceptive practices in women with CHD, describe adverse events associated with contraceptive use, and describe the provision of contraception counseling. Women >18years were recruited from 2011 to 2014 from 9 adult CHD (ACHD) centers throughout North America. Subjects completed a 48-item questionnaire regarding contraceptive use and perceptions of contraception counseling, and a medical record review was performed. Of 505 subjects, median age was 33 (interquartile range 26 to 44) and 81% had CHD of moderate or great complexity. The majority (86%, 435 of 505) of the cohort had used contraception. The types included barrier methods (87%), oral contraception (OC) 84%, intrauterine device (18%), Depo-Provera (15%), vaginal ring (7%), patch (6%), hormonal implant (2%), Plan B (19%), and sterilization (16%). Overall OC use was not significantly different by CHD complexity. Women with CHD of great complexity were more likely to report a thrombotic event while taking OC than those with less complex CHD (9% vs 1%, p= 0.003). Contraception counseling by the ACHD team was noted by 43% of subjects. Unplanned pregnancy was reported by 25% with no statistical difference by CHD complexity. In conclusion, contraceptive practices of women with complex CHD are highly variable, and the prevalence of blood clots while taking OC is not insignificant while provision of contraception counseling by ACHD providers appears lacking.

View details for DOI 10.1016/j.amjcard.2016.11.047

View details for PubMedID 28087052

Update on second-trimester surgical abortion. Current opinion in obstetrics & gynecology Shaw, K. A., Lerma, K. 2016; 28 (6): 510-516


To review the recent literature on surgical second-trimester abortion, with specific attention to cervical preparation techniques.Confirming previous studies, a recent retrospective observational cohort study, including 54911 abortions, estimated the total abortion-related complication rate to be 0.41% for second-trimester or later procedures. Cervical preparation is known to reduce risks associated with second-trimester dilation and evacuation (D&E). When considering adjuncts to osmotic dilators for cervical preparation prior to D&E after 16 weeks, both misoprostol and mifepristone are effective alone and in combination or as adjuncts to osmotic dilators. Misoprostol consistently has been shown to cause more pain and cramping than placebo, but is an effective adjunct to osmotic dilators after 16 weeks. Although mifepristone has fewer side-effects, at its current price, it may not be as cost-effective as misoprostol.Second-trimester abortion is safe. The use of mifepristone and misoprostol for second-trimester abortion has improved safety and efficacy of medical and surgical methods when used alone or in combination and as adjuncts to osmotic dilators. An important aspect of D&E, cervical preparation, is not a one-size-fits-all practice; the approach and methods are contingent on patient, provider and setting and should consider all the evidence-based options.

View details for PubMedID 27684047

Assessment of a simplified insertion technique for intrauterine devices INTERNATIONAL JOURNAL OF GYNECOLOGY & OBSTETRICS Christenson, K., Lerma, K., Shaw, K. A., Blumenthal, P. D. 2016; 134 (1): 29-32


To explore a simplified technique for intrauterine device (IUD) insertion.The present prospective longitudinal study enrolled patients aged at least 18years presenting at the gynecology clinic of Stanford University for IUD insertion between June 1, 2013 and June 30, 2014. No pelvic examination or uterine sounding was performed prior to IUD insertion. Transvaginal ultrasonography was performed immediately after insertion and at 4-6weeks to confirm device placement. The primary outcome was successful IUD placement.The study enrolled 50 patients. IUD insertion was completed successfully without any cervical manipulation in 40 (80%) participants. Sounding was not needed for any procedures. A cervical dilator was required to locate the internal os for 10 (20%) patients. The mean distance between IUDs and the endometrial verge immediately following insertion was 2.9mm. IUD insertion was rated "difficult" by the physician performing the procedure in 3 (6%) patients. No perforations were recorded. IUD expulsion occurred in 3 (6%) patients; menorrhagia was the indication for IUD insertion in two of these patients.IUD insertion without prior pelvic examination and sounding was feasible; this technique could reduce the need for instrument use during insertion and, consequently, the pain associated with insertion.

View details for DOI 10.1016/j.ijgo.2015.12.004

View details for PubMedID 27113419

Immediate postpartum provision of long-acting reversible contraception. Current opinion in obstetrics & gynecology Goldthwaite, L. M., Shaw, K. A. 2015; 27 (6): 460-464


The objective of this review is to describe current literature regarding the role and characteristics of long-acting reversible contraception (LARC) used immediately postpartum.Copper and levonorgestrel intrauterine devices (IUDs) inserted immediately postpartum at the time of both vaginal and cesarean deliveries are associated with higher rates of continuation at 6-12 months when compared with IUDs placed at the postpartum visit (4-8 weeks after delivery), despite higher rates of expulsion. IUDs and contraceptive implants are cost-effective when used immediately postpartum, and they are associated with longer interpregnancy intervals. There is limited evidence regarding the effects of immediate postpartum LARC on breastfeeding.Use of LARC methods in the immediate postpartum period is both effective and safe, and could reduce unmet need for contraception during this time. More research is needed to explore various immediate postpartum IUD insertion methods and the effects of immediate postpartum progestin-containing LARC on breastfeeding.

View details for DOI 10.1097/GCO.0000000000000224

View details for PubMedID 26536209

Update on long-acting reversible methods. Current opinion in obstetrics & gynecology Conti, J., Shaw, K. 2015; 27 (6): 471-475


The last several years have seen a number of important clinical and academic advances in long-acting reversible contraceptive (LARC) methods, such that many professional medical organizations now recommend these methods as first-line contraception for all women.Recent data support the use of LARC in a variety of special circumstances including adolescents, nulliparous women and immediately postpartum and postabortion. Evidence also shows that traditional methods of pain control with intrauterine device (IUD) insertion and cervical preparation prior to insertion may not be warranted. Further, the extended use of IUDs is safer and more effective than previously realized.The rising uptake of LARC methods in the United States has the potential to dramatically decrease undesired pregnancies and abortion rates, and should be considered an effective option in the majority of women.

View details for DOI 10.1097/GCO.0000000000000227

View details for PubMedID 26536210

In reply. Obstetrics and gynecology Shaw, J. G., Asch, S. M., Frayne, S. M., Phibbs, C. S., Kimerling, R., Shaw, K. A. 2015; 125 (4): 989-?

View details for DOI 10.1097/AOG.0000000000000783

View details for PubMedID 25798980

Posttraumatic stress disorder and risk of spontaneous preterm birth. Obstetrics and gynecology Shaw, J. G., Asch, S. M., Kimerling, R., Frayne, S. M., Shaw, K. A., Phibbs, C. S. 2014; 124 (6): 1111-1119


To evaluate the association between antenatal posttraumatic stress disorder (PTSD) and spontaneous preterm delivery.We identified antenatal PTSD status and spontaneous preterm delivery in a retrospective cohort of 16,334 deliveries covered by the Veterans Health Administration from 2000 to 2012. We divided mothers with PTSD into those with diagnoses present the year before delivery (active PTSD) and those only with earlier diagnoses (historical PTSD). We identified spontaneous preterm birth and potential confounders including age, race, military deployment, twins, hypertension, substance use, depression, and results of military sexual trauma screening and then performed multivariate regression to estimate adjusted odds ratio (OR) of spontaneous preterm delivery as a function of PTSD status.Of 16,334 births, 3,049 (19%) were to mothers with PTSD diagnoses, of whom 1,921 (12%) had active PTSD. Spontaneous preterm delivery was higher in those with active PTSD (9.2%, n=176) than those with historical (8.0%, n=90) or no PTSD (7.4%, n=982) before adjustment (P=.02). The association between PTSD and preterm birth persisted, when adjusting for covariates, only in those with active PTSD (adjusted OR 1.35, 95% confidence interval [CI] 1.14-1.61). Analyses adjusting for comorbid psychiatric and medical diagnoses revealed the association with active PTSD to be robust.In this cohort, containing an unprecedented number of PTSD-affected pregnancies, mothers with active PTSD were significantly more likely to suffer spontaneous preterm birth with an attributable two excess preterm births per 100 deliveries (95% CI 1-4). Posttraumatic stress disorder's health effects may extend, through birth outcomes, into the next generation.

View details for DOI 10.1097/AOG.0000000000000542

View details for PubMedID 25415162

Ensuring human rights in the provision of contraceptive information and services: Guidance and recommendations Shaw (Contributor), K. World Health Organization. 2014


BACKGROUND: Hormonal contraception is the most common medication used by reproductive aged women but there is little understanding of the impact of hormonal contraception on obesity and metabolism. Adipokine levels (adiponectin, resistin) and markers of adipocyte development (DLK-1) are altered in obese animals and humans and are associated with increased cardiovascular risk. We sought to determine the effect of combined hormonal oral contraceptive pills (COCs) on circulating adiponectin, resistin and DLK-1 levels in obese and normal-weight rhesus macaque monkeys. METHODS: Serum adiponectin, resistin and DLK-1 levels in reproductive-age female rhesus macaques of normal (n = 5, mean = 5.76 kg) and inherently obese (n = 5, mean = 8.11 kg) weight were determined before, during and 2 months after cessation of 8 months of continuous treatment with COCs. RESULTS: The obese group alone showed a significant decrease (p<.01) in weight with COC use, which returned to baseline after COC cessation. Baseline adiponectin levels prior to COC treatment were lower in the obese group (p<.05). Adiponectin levels increased from baseline in both groups, but more so in the obese group (p<.05). Resistin levels were similar at baseline, with an increase in both groups following treatment. Circulating resistin remained elevated above baseline levels after COC cessation, particularly in the obese group (p<.05). While DLK-1 levels did not change significantly in either group, a trend for higher levels in obese animals was observed. CONCLUSIONS: COC use may alter metabolic processes via direct (resistin) or indirect (adiponectin) means, while unchanging DLK1 levels suggest they do not affect adipocyte development. COCs may directly increase resistin levels, as observed in both groups. As adiponectin is inversely related to adipocyte mass, increased levels in the obese group are likely attributed to weight loss.

View details for DOI 10.1016/j.contraception.2012.10.029

View details for PubMedID 23218850

Effect of a combined estrogen and progesterone oral contraceptive on circulating adipocytokines adiponectin, resistin and DLK-1 in normal and obese female rhesus monkeys. Contraception Shaw, K. A., Hennebold, J. D., Edelman, A. B. 2013; 88 (1): 177-182


Obesity and unintended pregnancy are two of the major health epidemics we are currently facing worldwide. Patient education is a clinician's greatest tool in combating both epidemics but many clinicians may be uncomfortable with counselling and prescribing contraception for obese women. Overall, the prevention of unintended pregnancy in obese women far outweighs any risk associated with oral contraceptive use. This review aims to provide the clinician with a practical guide to the use of oral contraceptive pills in obese women.

View details for DOI 10.1016/j.beem.2012.09.001

View details for Web of Science ID 000315003700007

View details for PubMedID 23384746

Obesity and oral contraceptives: A clinician's guide BEST PRACTICE & RESEARCH CLINICAL ENDOCRINOLOGY & METABOLISM Shaw, K. A., Edelman, A. B. 2013; 27 (1): 55-65


At just one-third of the American population, those with a normal body mass index are now in the minority in the United States, whereas 68% are overweight or obese. The key to reducing the prevalence of obesity and improving the health of our population is, of course, screening and prevention. Screening (as simple as a weight and height) is effective, inexpensive, and already part of the routine vital signs taken at every visit. However, providers often avoid tackling the issue of weight due to a misperception that treatment is not effective, or from fear of causing offense or compromising rapport. However, clearly more harm is done by not discussing this important health issue. Cardiovascular disease remains the number 1 killer of women, and obesity is the leading modifiable risk factor. Beyond heart disease, obesity has implications for every visit type seen in the OB/GYN office, from contraception to pregnancy to abnormal bleeding to cancer. In addition, maternal obesity adversely affects future generations, making the impact of obesity a never-ending cycle. OB/GYNs are often the only physicians that reproductive-aged women see, and, thus, OB/GYNs have the opportunity to provide a potentially life-altering intervention. Effective treatment is available and includes lifestyle changes, behavioral counseling, medication, and bariatric surgery. Time is always a limitation in a busy practice but becoming more comfortable with how to approach patients, the language to use and tailoring counseling can save time increase impact.

View details for DOI 10.1097/OGX.0b013e318259ee6a

View details for Web of Science ID 000306740700017

View details for PubMedID 22713163

The Unmet Need for Family Planning Around the Globe for Women's Health: A Practical Guide for the Health Care Provider Atrio, J. M., Shaw, K. A., Blumenthal, P. D. Springer. 2013; 2013th
Obesity Epidemic: How to Make a Difference in a Busy OB/GYN Practice OBSTETRICAL & GYNECOLOGICAL SURVEY Shaw, K. A., Caughey, A. B., Edelman, A. B. 2012; 67 (6): 365-373