Clinical Focus

  • Complex Family Planning

Academic Appointments

Boards, Advisory Committees, Professional Organizations

  • Member, California Future of Abortion (FAB) Council (2021 - Present)
  • Delegate to California Medical Association, ACOG (2021 - Present)
  • Junior Fellow Legislative Advocate, ACOG (2016 - 2020)

Professional Education

  • Fellowship: Stanford University Family Planning Fellowship (2022) CA
  • MS, Stanford University, Epidemiology and Clinical Research (2022)
  • Board Certification: American Board of Obstetrics and Gynecology, Complex Family Planning (2022)
  • Fellowship, Stanford University Obstetrics and Gynecology, Complex Family Planning (2022)
  • Board Certification: American Board of Obstetrics and Gynecology, Obstetrics and Gynecology (2021)
  • Residency: Stanford University Obstetrics and Gynecology Residency (2020) CA
  • Medical Education: Georgetown University Office of the Registrar (2016) DC
  • BA, St. Olaf College (2010)
  • MD, Georgetown University School of Medicine (2016)

Clinical Trials

  • Cabergoline for Lactation Inhibition After Early Second-Trimester Abortion or Pregnancy Loss Not Recruiting

    Breast pain following second-trimester abortion is common. Breast engorgement and milk leakage following second-trimester perinatal loss and abortion can cause both physical pain and emotional distress. Dopamine agonists have previously been shown to be effective in lactation inhibition for third-trimester fetal/neonatal loss or contraindications to breastfeeding. The investigator's prior work demonstrated that compared to placebo, a single dose of cabergoline was effective in preventing breast symptoms after abortion or loss 18-28 weeks. As lactogenesis starts as early as 16 weeks gestation, the investigators hope to determine the efficacy of cabergoline earlier in the second trimester,16-20 weeks.

    Stanford is currently not accepting patients for this trial.

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  • Cabergoline for Lactation Inhibition After Second-Trimester Abortion or Loss Not Recruiting

    This research study investigates the use of a drug, cabergoline, given immediately after second-trimester abortion or perinatal loss to decrease breast engorgement. Cabergoline is a medication approved for the symptomatic treatment of pituitary adenomas that result in a hyperprolactinemic state (a brain tumor that results in milk leakage). The benefit of stopping milk leakage has also been studied and used in populations who shouldn't breastfeed. The investigators aim to clarify if cabergoline is effective in preventing breast engorgement and milk leakage after second-trimester abortions or perinatal loss (stillbirth). Breast engorgement causes physical pain and emotional distress as lactation is uniquely associated with parenthood and those undergoing second-trimester abortions are doing so because they choose not to parent or a previously desired pregnancy is now complicated by anomalies. As there are no current recommendations for management of this painful engorgement beyond icepacks and support bras, the investigators aim to validate the use of this pharmacologic option in this setting.

    Stanford is currently not accepting patients for this trial. For more information, please contact Andrea Henkel, MD, 650-721-1562.

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  • Transcutaneous Electrical Nerve Stimulation for Pain Control During First-trimester Abortion Not Recruiting

    First-trimester abortion aspiration procedures are painful and sedation is typically provided. It is unsafe to drive after sedation due to the prolonged motor delay from some anesthetic agents. Without a known escort, most clinics do not allow patients to use public transportation, taxis, or rideshare services. Arranging a ride may be harder for those seeking abortion care than other surgical procedures given privacy concerns and the need to travel far distances. Additionally, some people have medical reasons that makes sedation in an outpatient abortion clinic unsafe. As abortion restrictions increase and more people need to travel far distances to access care, it is important to investigate non-pharmacologic pain control options. Transcutaneous electrical nerve stimulation (TENS) delivers a low-level electrical current through the skin. By activating the descending inhibitory systems in the central nervous system, these pulses of electrical current reduce sensitivity to pain. TENS has been shown to be effective in decreasing pain with menstrual cramps and during medication abortion, and it was found to be non-inferior to IV sedation for first-trimester procedural abortion. However, it remains unclear if TENS is better than ibuprofen and local anesthesia via paracervical block alone. The overarching goal of this research is to identify an inexpensive, non-pharmacologic, alternative pain control strategy for those with a medical or social contraindication to IV sedation. The specific aim of this project is to evaluate the efficacy of TENS to prevent pain during first-trimester procedural abortion. To achieve this objective, a blinded, randomized superiority trial comparing the use of TENS to sham for management of pain during first-trimester aspiration abortion is proposed. This research is significant because the validation of a non-pharmacologic pain management technique would decrease barriers to accessing abortion care.

    Stanford is currently not accepting patients for this trial.

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All Publications

  • Utilising fruits to enhance first-trimester abortion simulation: can we do better than a papaya? BMJ sexual & reproductive health Owens, S. N., Kaur, S., Henkel, A. 2024

    View details for DOI 10.1136/bmjsrh-2024-202354

    View details for PubMedID 38834284

  • Mifepristone and Misoprostol in California pharmacies after modifications to the Risk Evaluation and Mitigation Strategy Program. Contraception Beshar, I., Miller, H. E., Kruger, S., Henkel, A. 2024: 110506


    In January 2023, the Food & Drug Administration modified the Risk Evaluation and Mitigation Strategy (REMS) program regulating mifepristone to allow direct dispensation from retail pharmacies. In June 2023, we conducted a random, distributive survey of pharmacies in California using secret shopper methodology to investigate the feasibility of accessing mifepristone. One pharmacy had mifepristone immediately available (<24 hours) and misoprostol availability was limited. Accessibility to misoprostol varied by type of pharmacy (p<0.01), but not by region. Even in a reproductive freedom state, access to mifepristone and misoprostol from outpatient retail pharmacies remains limited.

    View details for DOI 10.1016/j.contraception.2024.110506

    View details for PubMedID 38806139

  • Prevalence and Characteristics of Emergency Department Visits by Pregnant People: An Analysis of a National Emergency Department Sample (2010-2020). The western journal of emergency medicine Preiksaitis, C., Saxena, M., Zhang, J., Henkel, A. 2024; 25 (3): 436-443


    Introduction: The number and characteristics of pregnant patients presenting to the emergency department (ED) has not been well described. Our objective in this study was to determine the prevalence and characteristics of pregnant patients presenting to EDs in the US between 2010-2020.Methods: We completed a retrospective, cross-sectional study of patient encounters at hospital-based EDs in the US from 2010-2020. Using the ED subsample of the National Hospital Ambulatory Medical Care Survey (NHAMCS) we identified ED visits for female patients aged 15-44years. We defined a subsample of these as visits for pregnant patients using discharge diagnosis codes specific to pregnancy. We compared this population of pregnant patient visits to those for non-pregnant patients and computed point estimates for nationally weighted values. Multivariable linear regression was used to determine factors independently associated with pregnant patient visits.Results: The 2010-2020 NHAMCS dataset included 255,963 ED visits. Of these visits 59,080 were for female patients 15-44years old, and 6,068 of those visits were for pregnant patients. Pregnant patients accounted for 3% (95% confidence interval [CI] 2.7-3.2) of all ED visits and 8.6% (95% CI 8-9.3) of all visits among female patients 15-44years. Weighting to a national sample, this equates to 2.77 million pregnant patients presenting for ED visits annually. Pregnant patients were more likely to be Black, Hispanic, or to use public insurance.Conclusion: Pregnant patients make up a significant number of ED visits annually and are more likely to be people of color or publicly insured. Interventions to address the effects of changing abortion legislation on emergency medicine practice may benefit from consideration that certain populations of pregnant people are more likely to present to the ED for care.

    View details for DOI 10.5811/westjem.60461

    View details for PubMedID 38801052

  • Risk Factors Associated With Being Lost to Follow-up Among Patients With Pregnancy of Unknown Location Beshar, I., Doyle, A. A., Henkel, A., Padron, E., Liu, S., Shorter, J. LIPPINCOTT WILLIAMS & WILKINS. 2024: 13S
  • Initiating medical abortion in an emergency department in the United States. BMJ sexual & reproductive health Preiksaitis, C., Saxena, M., Henkel, A. 2024


    The primary objective of this study was to assess the feasibility of initiating medical abortions in a large, academic emergency department (ED) in the United States.A retrospective case series analysis was conducted to evaluate a protocol for initiating medical abortion in the ED implemented from January 2020 to October 2023 at an academic, tertiary care hospital in California, USA. Participants included ED patients diagnosed with pregnancies in the first trimester that were undesired and who opted for medical abortion. The medical abortion protocol was collaboratively designed by a multidisciplinary team and follow-up was conducted by our institution's gynaecology department. Data were sourced from a data repository of electronic health records and subjected to descriptive statistical analysis.A total of 27 eligible patients initiated medical abortions in the ED during the study period. The cohort was diverse in terms of racial and ethnic backgrounds and almost evenly split between private and public insurance. No patients had significant complications identified in the medical record. Two patients required uterine aspiration by the gynaecology team; one patient in clinic and one during a return visit to the ED.Data from this case series suggest that initiating medical abortion in the ED is feasible. The ED may be considered as an additional access point for abortion care services, especially in areas where other care options are not readily available. Educational, legal and regulatory frameworks that allow emergency physicians to take a greater role in providing this care should be considered.

    View details for DOI 10.1136/bmjsrh-2023-202149

    View details for PubMedID 38365454

  • Intrahepatic Cholestasis of Pregnancy and Transaminitis in Women with COVID-19: A Case Series. AJP reports Waldrop, A. R., Henkel, A., Lee, K. B., Druzin, M. L., Aziz, N., El-Sayed, Y., Lyell, D. J. 2024; 14 (1): e16-e18


    Objective  The four initial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected pregnant women presenting at term gestation to our institution presented with transaminitis. Three of the four were diagnosed with intrahepatic cholestasis of pregnancy (IHCP). Growing evidence exists of an associated transaminitis in nonpregnant SARS-CoV-2 patients. However, there are limited data of hepatic involvement of SARS-CoV-2 in pregnancy, and no previous studies have assessed the association with IHCP in patients with coronavirus disease 2019 (COVID-19). Study Design  This was a retrospective, single-center case series of four consecutive pregnant women with a positive result for SARS-CoV-2 presenting with transaminitis in third trimester. Results  The clinical courses of four pregnant women with COVID-19 and transaminitis, three of four of whom were diagnosed with IHCP, are described. Testing for SARS-CoV-2 was done through a reverse transcription polymerase chain reaction test of a nasopharyngeal swab. Conclusion  As we await larger studies ascertaining the incidence of IHCP in SARS-CoV-2, this prevalence highlights the importance of diagnosing IHCP among women with COVID-19 as a potential etiology of transaminitis, as IHCP risks may be ameliorated with earlier delivery. Moreover, delineating a hepatobiliary association in pregnancy may provide further information about the mechanism of liver impairment in SARS-CoV-2 in all patients.

    View details for DOI 10.1055/s-0043-1777999

    View details for PubMedID 38269122

    View details for PubMedCentralID PMC10805562

  • 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

  • The evolving role of emergency medicine in family planning services. Current opinion in obstetrics & gynecology Preiksaitis, C., Henkel, A. 2023


    The emergency department serves as an essential access point for a variety of healthcare services. This review will examine the recent expansion of family planning and reproductive health services in the emergency department.An increasing number of patients present to emergency departments for early pregnancy loss (EPL), abortion care, and contraceptive management. Availability of comprehensive EPL management varies dramatically, possibly due to lack of provider knowledge or training. Particularly in remote settings, educational interventions - such as providing information about medication management and training in uterine aspiration - may standardize this management. Restrictive abortion laws raise concerns for changing and increased patient presentations to the emergency department for complications related to unsafe or self-managed abortion. Emergency medicine providers should anticipate that more patients will present without a prior ultrasound confirming intrauterine pregnancy prior to initiating no-touch or self-managed abortions. Particularly among pediatric patients, there may be a role for contraceptive counseling during an emergency department visit. Novel strategies, including web-based interventions and emergency department-based curricula for contraceptive counseling, may help reach those who otherwise may not seek reproductive healthcare in a clinic setting.The intersection of emergency medicine and reproductive healthcare is a promising frontier for providing immediate, patient-centered, family planning care. Continued research and provider education are necessary to refine these approaches, address disparities, and respond to the changing reproductive healthcare landscape.

    View details for DOI 10.1097/GCO.0000000000000908

    View details for PubMedID 37610990

  • Lactational Amenorrhea Method for Postpartum Contraception: a content analysis of YouTube videos. American journal of obstetrics & gynecology MFM Henkel, A., Rice, K. P., Parameshwar, P. S., Cahill, E. P. 2023: 101122

    View details for DOI 10.1016/j.ajogmf.2023.101122

    View details for PubMedID 37549735

  • Abortion Bans and Resource Utilization for Congenital Heart Disease: A Decision Analysis. Obstetrics and gynecology Miller, H. E., Fraz, F., Zhang, J., Henkel, A., Leonard, S. A., Maskatia, S. A., El-Sayed, Y. Y., Blumenfeld, Y. J. 2023


    To investigate the implications of potential national abortion ban scenarios on the incidence of neonatal single-ventricle cardiac defects.A decision tree model was developed to predict the incidence of neonatal single-ventricle cardiac defects and related outcomes in the United States under four theoretical national abortion bans: 1) abortion restrictions in existence immediately before the June 2022 Dobbs v Jackson Women's Health Organization Supreme Court decision, 2) 20 weeks of gestation, 3) 13 weeks of gestation, and 4) a complete abortion ban. The model included incidence of live births of neonates with single-ventricle cardiac defects, neonatal heart surgery (including heart transplant and extracorporeal membrane oxygenation [ECMO]), and neonatal death. Cohort size was based on national pregnancy incidence and different algorithm decision point probabilities were aggregated from the existing literature. Monte Carlo simulations were conducted with 10,000 iterations per model.In the scenario before the Dobbs decision, an estimated 6,369,000 annual pregnancies in the United States resulted in 1,006 annual cases of single-ventricle cardiac defects. Under a complete abortion ban, the model predicted a 53.7% increase in single-ventricle cardiac defects, or an additional 9 cases per 100,000 live births. This increase would result in an additional 531 neonatal heart surgeries, 16 heart transplants, 77 ECMO utilizations, and 102 neonatal deaths annually. More restrictive gestational age-based bans are predicted to confer increases in cases of neonatal single-ventricle cardiac defects and related adverse outcomes as well.Universal abortion bans are estimated to increase the incidence of neonatal single-ventricle cardiac defects, associated morbidity, and resource utilization. States considering limiting abortion should consider the implications on the resources required to care for increasing number of children that will be born with significant and complex medical needs, including those with congenital heart disease.

    View details for DOI 10.1097/AOG.0000000000005291

    View details for PubMedID 37535962

  • The cost of loss: a secret shopper survey of mortuary disposition of fetal remains AMERICAN JOURNAL OF OBSTETRICS & GYNECOLOGY MFM Henkel, A., Burns, R. M., Spach, N. C., Cahill, E. P. 2023; 5 (7)
  • The cost of loss: a secret shopper survey of mortuary disposition of fetal remains. American journal of obstetrics & gynecology MFM Henkel, A., Burns, R. M., Spach, N. C., Cahill, E. P. 2023; 5 (7): 100986

    View details for DOI 10.1016/j.ajogmf.2023.100986

    View details for PubMedID 38236699

  • 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, α=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

  • Abortion restriction impact on burden of neonatal single ventricle congenital heart disease: a decision-analytic model Miller, H. E., Henkel, A., Zhang, J., Leonard, S. A., Quirin, A. P., Maskatia, S. A., El Sayed, Y. Y., Blumenfeld, Y. J. MOSBY-ELSEVIER. 2023: S483
  • Words matter: perforation or transmural migration? BMJ sexual & reproductive health Amaya, S. I., Henkel, A., Blumenthal, P. D. 2022

    View details for DOI 10.1136/bmjsrh-2022-201738

    View details for PubMedID 36564157

  • 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

  • Optimizing postpartum contraception for high-risk obstetric patients. Current opinion in obstetrics & gynecology Miller, H. E., Darmawan, K. F., Henkel, A. 2022


    PURPOSE OF REVIEW: This review will focus on those who are at greatest risk of maternal and neonatal morbidity from a subsequent unplanned or short interval pregnancy and the interventions to increase contraceptive uptake in the postpartum period.RECENT FINDINGS: Populations at highest risk of maternal or neonatal morbidity - those with a history of preterm birth or those with complex medical conditions - are also those at the highest risk for unintended pregnancies attributed to low-efficacy contraceptive failure/ noncontraceptive use, and many are discharged from birth hospitalization without understanding the importance of birth spacing related to their high-risk pregnancies. Current innovative strategies to improve postpartum contraception access and uptake among high-risk populations include utilizing the antenatal period to initiate contraception counseling, developing multidisciplinary teams, and incorporating multimedia-based educational tools. However, ongoing challenges that continue to pose barriers to contraception access include racial and economic disparities and the restructuring of obstetric care during the COVID-19 pandemic.SUMMARY: Preventing an unintended short interval pregnancy by providing contraception in the postpartum period is one of the most modifiable risk factors for those at highest risk of subsequent maternal or neonatal morbidity and therefore should be prioritized by clinicians, hospitals, and insurance coverage.

    View details for DOI 10.1097/GCO.0000000000000816

    View details for PubMedID 36165024

  • 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

  • Second-trimester abortion care for those with complex medical conditions. Current opinion in obstetrics & gynecology Henkel, A., Blumenthal, P. D. 2022


    PURPOSE OF THE REVIEW: This review focuses on patients who are most likely to experience morbidity associated with second trimester abortion care and risk mitigation strategies.RECENT FINDINGS: Prior cesarean birth, particularly multiple prior cesarean births, is the most significant risk factor associated with complications during second trimester abortion because of increased risks of hemorrhage, with or without placenta accreta spectrum (PAS), and distorted anatomy, which increases the risk of uterine perforation. Recent data suggests that first trimester ultrasound findings may be predictive of PAS, including multiple lacunae, abnormal uteroplacental interface, and hypervascularity. Multiple common medications interact with mifepristone and are therefore contraindicated; ulipristal shares mifepristone's selective progesterone receptor modulator activity but does not share the same metabolic pathway. Recent data suggests ulipristal may be an effective adjunct for cervical preparation, avoiding potentially mifepristone's drug-drug interactions. Those ending a pregnancy due to severe early-onset hypertensive disorders have a high rate of clinically significant thrombocytopenia: platelet transfusion is recommended for those with platelets <50 000 per cubic millimeter.SUMMARY: Pregnant people presenting for care in the second trimester may have conditions that make an abortion more technically or medically complex. Clinicians can mitigate much of this increased risk with preprocedural planning, and appropriate intra-operative preparedness.

    View details for DOI 10.1097/GCO.0000000000000817

    View details for PubMedID 36036465

  • 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

  • The Cost of Loss: A Secret-Shopper Survey of Mortuary Disposition of Fetal Remains Burns, R., Henkel, A., Cahill, E. LIPPINCOTT WILLIAMS & WILKINS. 2022: 53S
  • Missing strings following immediate postpartum IUD placement. BMJ sexual & reproductive health Henkel, A., Blumenthal, P. D. 2022

    View details for DOI 10.1136/bmjsrh-2021-201400

    View details for PubMedID 35277465

  • Postpartum permanent contraception: updates on policy and access. Current opinion in obstetrics & gynecology Henkel, A., Beshar, I., Goldthwaite, L. M. 2021


    PURPOSE OF REVIEW: To describe barriers to provision of postpartum permanent contraception at patient, hospital, and insurance levels.RECENT FINDINGS: Permanent contraception remains the most commonly used form of contraception in the United States with the majority of procedures performed during birth-hospitalization. Many people live in regions with a high Catholic hospital market share where individual contraceptive plans may be refused based on religious doctrine. Obesity should not preclude an individual from receiving a postpartum tubal ligation as recent studies find that operative time is clinically similar with no increased risk of complications in obese compared with nonobese people. The largest barrier to provision of permanent contraception remains the federally mandated consent for sterilization for those with Medicaid insurance. State variation in enforcement of the Medicaid policy additionally contributes to unequal access and physician reimbursement. Although significant barriers exist in policy that will take time to improve, hospital-based interventions, such as listing postpartum tubal ligation as an 'urgent' procedure or scheduling interval laparoscopic salpingectomy prior to birth-hospitalization discharge can make a significant impact in actualization of desired permanent contraception for patients.SUMMARY: Unfulfilled requests for permanent contraception result in higher rates of unintended pregnancies, loss of self-efficacy, and higher costs. Hospital and federal policy should protect vulnerable populations while not preventing provision of desired contraception.

    View details for DOI 10.1097/GCO.0000000000000750

    View details for PubMedID 34534995

  • 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)
  • 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

  • Management of bothersome bleeding associated with progestin-based long-acting reversible contraception: a review. Current opinion in obstetrics & gynecology Henkel, A., Goldthwaite, L. M. 2020


    PURPOSE OF REVIEW: To describe common bleeding patterns and treatment strategies to minimize bothersome bleeding in users of progestin-based long-acting reversible contraception (LARC).RECENT FINDINGS: Most levonorgestrel intrauterine device users will establish a favorable bleeding pattern within a year; NSAIDs are the most effective bridge to help with bothersome bleeding during that time period. Early follicular phase insertion and fundal placement are associated with more favorable early bleeding profiles. Recent studies exploring tranexamic acid, mifepristone, and tamoxifen's adjunct role show modest or no benefit. The progestin implant is associated with more persistent unpredictable bleeding disproportionately affecting women with higher etonogestrel serum levels; recent studies indicate that oral contraceptives, ulipristal acetate, and tamoxifen may all provide temporary relief.SUMMARY: Women's healthcare providers can offer patients adjunct medical therapies to minimize bothersome bleeding associated with progestin LARC use, which may result in increased satisfaction and continuation rates of these effective forms of contraception.

    View details for DOI 10.1097/GCO.0000000000000664

    View details for PubMedID 32889971

  • 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

  • Postplacental intra-abdominal placement of levonorgestrel 52mg intrauterine system: a case report. Contraception Peterson, S. F., Henkel, A., Ganti, A., Blumenthal, P. D. 2020


    This case of an intra-abdominal levonorgestrel 52mg intrauterine system found three weeks after manual postplacental placement demonstrates the importance of proper insertion technique and ascertainment of fundal placement. Ultrasound guidance can be considered if fundal placement is uncertain. Short interval follow up should be recommended to confirm proper placement.

    View details for DOI 10.1016/j.contraception.2020.01.015

    View details for PubMedID 32081642

  • Preeclampsia Treatment in SARS-CoV-2. American journal of obstetrics & gynecology MFM Joudi, N. n., Henkel, A. n., Lock, W. S., Lyell, D. n. 2020: 100146

    View details for DOI 10.1016/j.ajogmf.2020.100146

    View details for PubMedID 32838258

    View details for PubMedCentralID PMC7237374

  • 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
  • Connect the Dots-March 2019. Obstetrics and gynecology Coney, T., Henkel, A., Plisko, A. M., Chescheir, N. C. 2019; 133 (3): 579-581

    View details for DOI 10.1097/AOG.0000000000003151

    View details for PubMedID 30741819

  • 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

  • Advances in the management of early pregnancy loss CURRENT OPINION IN OBSTETRICS & GYNECOLOGY Henkel, A., Shaw, K. A. 2018; 30 (6): 419–24
  • 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