New technologies permit safe abortion at less than six weeks' gestation and provide timely detection of ectopic gestation

doi:10.1016/S0002-9378(97)70410-1

American Journal of Obstetrics and Gynecology

Volume 176, Issue 5, May 1997, Pages 1101-1106

https://doi.org/10.1016/S0002-9378(97)70410-1 Get rights and content

Abstract

OBJECTIVE: The previously held dictum that elective abortion before 6 weeks' gestation carried greater risks than a later procedure was challenged by this protocol.

STUDY DESIGN: This study evaluated a protocol for abortion before the customary 6 weeks' gestation. Patients willing to return to the clinic within 72 hours were given the option of elective abortion even when no gestational sac could be visualized with transvaginal ultrasonography. When no chorionic membrane with villi was seen in the curettings, postoperative serum levels of β-human chorionic gonadotropin confirmed complete evacuation or diagnosed ectopic pregnancy.

RESULTS: In 1530 abortion procedures at <6 weeks' gestation by ultrasonographic criteria no serious complications occurred. In addition, 9 (0.67%) unsuspected ectopic pregnancies were diagnosed.

CONCLUSIONS: Abortion before 6 weeks' gestation is safe, given close surveillance. Early termination combined with vaginal ultrasonography and follow-up with β-human chorionic gonadotropin measurements allows diagnosis of early, unsuspected ectopic pregnancy. Ectopic pregnancy was found to be uncommon in women requesting early abortion. (Am J Obstet Gynecol 1997;176:1101-6.)

Section snippets

Material and methods

We performed 6947 first-trimester abortions at Planned Parenthood of Houston and Southeast Texas from Jan. 1, 1994, to Oct. 31, 1995. The patient was allowed to schedule an appointment as soon as she suspected that she was pregnant. Most patients had diagnosed pregnancy by a commercially available home pregnancy test before calling the clinic. On the patient's arrival at the clinic a urine pregnancy test was performed (sensitivity 25 mlU/ml hCG; Abbott Test Pak Plus, Abbott Laboratories, Abbott

Results

Of the 6947 first-trimester abortions performed during the study 1530 (22%) were <6 weeks' gestation by ultrasonographic criteria. No gestational sac was identified by ultrasonography in 153 patients; 9 (6%) of these had ectopic pregnancies.

Comment

Many women with an unwanted pregnancy desire access to abortion soon after the diagnosis of pregnancy. Although once thought to pose increased risks of incomplete abortion and undiagnosed ectopic pregnancy, advances in technology have allowed identification of incomplete abortion and early diagnosis of ectopic pregnancy. An advantage of early diagnosis of an asymptomatic ectopic pregnancy is that medical treatment with methotrexate is frequently efficacious, thereby avoiding a surgical

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Vaginal sonography versus serum human chorionic gonadotropin in early detection of pregnancy
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Reducing the morbidity of vacuum aspiration abortion
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Abortions that fail
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There are more references available in the full text version of this article.

Cited by (49)

Medication abortion and uterine aspiration for undesired pregnancy of unknown location: A retrospective cohort study
2023, Contraception
To compare days to diagnosis of pregnancy location for same-day medication abortion and same-day uterine aspiration with delayed treatment (expectant management) in patients with undesired pregnancy of unknown location (PUL).
We conducted a retrospective cohort study at a single Planned Parenthood health center in Minnesota. We reviewed electronic health records and included patients presenting for induced abortion diagnosed with PUL (positive high-sensitivity urine pregnancy test and no evidence of intrauterine or extrauterine pregnancy on transvaginal ultrasonography) without symptoms or ultrasonographic imaging concerning for ectopic pregnancy (low risk). The primary outcome was days to pregnancy location clinical diagnosis.
Of 19,151 abortion encounters in 2016–2019, 501 (2.6%) had a low-risk PUL. Participants chose delay-for-diagnosis before treatment (148, 29.5%), immediate treatment medication abortion (244, 48.7%), or immediate treatment uterine aspiration (109, 21.8%). Median days to diagnosis were significantly lower in the immediate treatment uterine aspiration group (2 days, IQR 1–3 days, p < 0.001) and similar for immediate treatment medication abortion (4 days, IQR 3–9 days, p = 0.304) compared with delay-for-diagnosis (3 days, IQR 2–10 days). Thirty-three low-risk participants (6.6%) were treated for ectopic pregnancy, but no difference in ectopic rate was detected among groups (p = 0.725). Participants in the delay-for-diagnosis group were more likely to be nonadherent with follow-up (p < 0.001). For participants who completed follow-up, abortion completion rate was lower for immediate treatment medication abortion (85.2%) compared with immediate treatment uterine aspiration (97.6%, p = 0.003).
For patients with undesired PUL, diagnosis of pregnancy location was fastest with immediate treatment uterine aspiration and similar for expectant management and immediate treatment medication abortion. Medication abortion efficacy may be reduced in treatment of undesired PUL.
For PUL patients desiring induced abortion, the option of proceeding at initial encounter may help improve access and patient satisfaction. Uterine aspiration for PUL may help diagnose pregnancy location more quickly.
Safety and effectiveness of medication and aspiration abortion before or during the sixth week of pregnancy: A retrospective multicenter study
2020, Contraception
To compare adverse outcomes of medication and aspiration abortion among those with intrauterine pregnancy <43 days gestation versus abortions performed at 43–48 days.
We conducted a multicenter retrospective chart review study to review all medication and aspiration abortion of visualized pregnancy <49 days gestation at Planned Parenthood Columbia Willamette (Oregon) and Planned Parenthood of Orange and San Bernardino Counties (California) in 2014–2015. We identified incident cases by billing codes and performed chart review for adverse outcomes (ED visits, incomplete abortion), need for further interventions, or complications (hemorrhage, infection, and uterine perforation), captured up to 90 days post-abortion.
The 3930 abortions during the study period at the two sites included 2914 medication abortions and 1016 aspiration abortions, with 1470 medication abortions and 469 aspiration abortions at <43 days gestation. Composite adverse outcomes did not vary by gestation, for either medication abortion (75/1470; 5.1% for <43 days versus 94/1444; 6.5% at 43–48 days, p = 0.10) or aspiration (12/469; 2.6% for <43 days versus 16/547; 2.9% at 43–48 days, p = 0.72). Fewer incomplete abortions (ongoing pregnancy, symptomatic retained tissue, or retained gestational sac) occurred in the earlier gestational group (3.1% for <43 days versus 4.3% at 43–48 days, p = 0.04). Composite adverse outcomes were higher after medication versus aspiration abortion (169/2914; 5.8% versus 28/1016; 2.7%, p < 0.01).
Medication and aspiration abortion performed either before or during the sixth week of ultrasound-confirmed intrauterine pregnancy have low rates of composite adverse outcomes, including complications or incomplete abortion. However, unplanned interventions are more common after medication compared to aspiration abortions.
Very early medication and aspiration abortion are similarly safe and effective before or during the sixth week of ultrasound-confirmed pregnancy, though subsequent interventions are more likely after medication abortion. Patients with early pregnancy can safely initiate abortion with follow-up to ensure complete abortion.
N<sup>o</sup> 360 - Avortement provoqué: avortement chirurgical et méthodes médicales au deuxième trimestre
2018, Journal of Obstetrics and Gynaecology Canada
La présente directive clinique examine les données probantes sur l'avortement chirurgical et l'avortement médical au deuxième trimestre, y compris les soins prodigués avant et après l'intervention.
Gynécologues, médecins de famille, infirmières, sages-femmes, résidents et autres fournisseurs de soins de santé qui pratiquent ou enseignent, ou ont l'intention de pratiquer ou d'enseigner, l'avortement provoqué (AP).
Femmes dont la grossesse de premier ou de deuxième trimestre est non désirée ou anormale.
Des recherches ont été menées dans PubMed, Medline et la base de données Cochrane à l'aide des mots-clés « first-trimester surgical abortion », « second-trimester surgical abortion », « second-trimester medical abortion », « dilation and evacuation », « induction abortion », « feticide », « cervical preparation », « cervical dilation » et « abortion complications ». Nous n'avons tenu compte que des revues systématiques, des essais cliniques randomisés, des essais cliniques et des études observationnelles de langue anglaise ou française publiés entre 1979 et juillet 2017. Des directives cliniques nationales et internationales ont été consultées. Nous n'avons pas effectué de recherches dans la littérature grise (non publiée).
La qualité des données probantes a été évaluée au moyen de l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation). Le résumé des conclusions peut être fourni sur demande.
L'AP est sûr et efficace. Les avantages en surpassent les dommages et les coûts potentiels. Aucun nouveau dommage ou coût direct n'a été associé à la présente directive clinique.
No. 360-Induced Abortion: Surgical Abortion and Second Trimester Medical Methods
2018, Journal of Obstetrics and Gynaecology Canada
Citation Excerpt :
The relative lack of tissue presents 2 diagnostic challenges. The first is ruling out ongoing pregnancy,132–134 which varies from 1.3 per 1000 under 6 weeks of gestation when performed by a skilled provider using routine preoperative and postoperative transvaginal ultrasound, direct examination of POC, and rigorous FU135,136 to 23 per 1000 when multiple providers are involved.137 The second diagnostic challenge is excluding EP in the setting of a PUL, when a yolk sac (and, in some instance, a definite GS) has not been seen.
This guideline reviews evidence relating to the provision of surgical induced abortion (IA) and second trimester medical abortion, including pre- and post-procedural care.
Gynaecologists, family physicians, nurses, midwives, residents, and other health care providers who currently or intend to provide and/or teach IAs.
Women with an unintended or abnormal first or second trimester pregnancy.
PubMed, Medline, and the Cochrane Database were searched using the key words: first-trimester surgical abortion, second-trimester surgical abortion, second-trimester medical abortion, dilation and evacuation, induction abortion, feticide, cervical preparation, cervical dilation, abortion complications. Results were restricted to English or French systematic reviews, randomized controlled trials, clinical trials, and observational studies published from 1979 to July 2017. National and international clinical practice guidelines were consulted for review. Grey literature was not searched.
The quality of evidence in this document was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology framework. The summary of findings is available upon request.
IA is safe and effective. The benefits of IA outweigh the potential harms or costs. No new direct harms or costs identified with these guidelines.
Surgical methods of abortion
2016, Journal de Gynecologie Obstetrique et Biologie de la Reproduction
Donner un état des lieux des preuves scientifiques concernant l’interruption volontaire de grossesse (IVG) instrumentale en axant la réflexion sur la limitation des risques et l’aspect pratique.
Une revue systématique de la littérature en langue française et anglaise, concernant la prise en charge des femmes en demande d’une IVG instrumentale, a été réalisée sur PubMed, Cochrane Library et sur les recommandations des sociétés savantes internationales.
L’IVG instrumentale a un taux de succès élevé, quel que soit l’âge gestationnel, y compris avant 7 SA (NP2). Le choix de la méthode instrumentale ou médicamenteuse devrait être laissé aux femmes (grade B). Une antibioprophylaxie systématique doit être préférée à une antibioprophylaxie ciblée (grade A). Chez la femme de moins de 25 ans, la doxycycline est privilégiée (grade C) du fait de la prévalence élevée de Chlamydiae trachomatis. La préparation cervicale systématique est recommandée en vue de diminuer les complications liées au geste (accord professionnel). Le misoprostol en est un agent de première intention (grade A). Lorsque le misoprostol est utilisé avant une aspiration évacuatrice, une dose de misoprostol à 400 μg est recommandée. Il sera donné au choix de la patiente : (i) par voie vaginale 3 heures avant le geste (grade A) du fait de son bon rapport efficacité/tolérance ; (ii) par voie sublinguale 1 à 3 heures avant le geste (grade A) du fait d’une efficacité supérieure (NP1). La femme sera prévenue d’effets indésirables gastro-intestinaux plus fréquents que la voie vaginale (grade B). L’adjonction de 200 mg de mifépristone 24 à 48 heures avant le geste est intéressante pour les grossesses comprises entre 12 et 14 SA (NP2). L’utilisation d’anti-inflammatoires non stéroïdiens est recommandée en routine pour limiter les douleurs opératoires et postopératoires (grade B). L’application vaginale d’un antiseptique préalablement à la procédure d’IVG instrumentale ne peut pas être recommandée en systématique (grade B). Le type d’anesthésie (générale ou locale) doit être laissé au choix de la patiente après explication du rapport bénéfice-risque (grade B). Une anesthésie locale paracervicale est recommandée avant la réalisation d’une IVG instrumentale sous anesthésie locale (grade A). L’aspiration électrique ou manuelle sont des méthodes très efficaces, à faible risque et acceptables par les femmes (grade A). Avant 9 SA, la technique manuelle aurait un intérêt subjectif sur le vécu des femmes (grade B). La méthode par aspiration électrique est à privilégier après 9 SA (accord professionnel). Dans une grossesse de localisation indéterminée, une baisse de l’HCG d’au moins 50 % à j5 et 80 % à j7 permet de raisonnablement conclure au succès de la procédure (NP3). Le paracétamol ou l’association paracétamol et codéine n’a pas démontré d’intérêt dans l’antalgie après une IVG instrumentale. Elle n’est donc pas recommandée (grade B).
A state of the art of surgical method of abortion focusing on safety and practical aspects.
A systematic review of French-speaking or English-speaking evidence-based literature about surgical methods of abortion was performed using Pubmed, Cochrane and international recommendations.
Surgical abortion is efficient and safe regardless of gestational age, even before 7 weeks gestation (EL2). A systematic prophylactic antibiotics should be preferred to a targeted antibiotic prophylaxis (grade A). In women under 25 years, doxycycline is preferred (grade C) due to the high prevalence of Chlamydia trachomatis. Systematic cervical preparation is recommended for reducing the incidence of complications from vacuum aspiration (grade A). Misoprostol is a first-line agent (grade A). When misoprostol is used before a vacuum aspiration, a dose of 400 mcg is recommended. The choice of vaginal route or sublingual administration should be left to the woman: (i) the vaginal route 3 hours before the procedure has a good efficiency/safety ratio (grade A); (ii) the sublingual administration 1 to 3 hours before the procedure has a higher efficiency (EL1). The patient should be warned of more common gastrointestinal side effects. The addition of mifepristone 200 mg 24 to 48 hours before the procedure is interesting for pregnancies between 12 and 14 weeks gestations (EL2). The systematic use of nonsteroidal anti-inflammatory drugs is recommended for limiting the operative and postoperative pain (grade B). Routine vaginal application of an antiseptic prior to the procedure cannot be recommended (grade B). The type of anesthesia (general or local) should be left up to the woman after explanation of the benefit-risk ratio (grade B). Paracervical local anesthesia (PLA) is recommended before performing a vacuum aspiration under local anesthesia (grade A). The electric or manual vacuum methods are very effective, safe and acceptable to women (grade A). Before 9 weeks gestation, the manual vacuum aspiration could have a subjective interest (grade B). The electric vacuum aspiration is recommended after 9 weeks gestation (best practice agreement). For a pregnancy of unknown location, the success of the procedure can reasonably be determined if hCG drops more than 50 % on day 5 and 80 % on day 7 (NP3). After a surgical abortion, paracetamol or addition of paracetamol and codeine is not recommended (grade B).
Medical Abortion
2016, Journal of Obstetrics and Gynaecology Canada
Citation Excerpt :
The risk of ectopic pregnancy (EP) in the general population is about 1%–2%.78,105 In abortion clinics, the rate of EP is consistently lower than baseline population rates.106,107 A 2009–2010 review of 233 805 MAs performed at Planned Parenthood Federation of America (PPFA) clinics in the United States showed that the rate of EP was 0.7 per 10 000 MAs (0.007%).108
This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care.
Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services.
Women with an unintended first trimester pregnancy.
Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required.
The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1).
Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability.
Introduction
- 1.
  In countries where mifepristone is approved, women have improved access to medical abortion; however, abortion rates do not increase. (Level II-3)
- 2.
  Women who can choose their method of abortion have higher satisfaction rates. (Level II-1)
Pre-procedure care
- 3.
  In the absence of readily accessible ultrasound, gestational age can be estimated using last menstrual period (LMP), clinical history, and physical examination, in women who are certain of the date of their LMP. Ultrasound is needed when uncertainty remains. (Level II-2)
- 4.
  The probability of ectopic pregnancy among women requesting abortion is consistently lower than in the general population. (Level II-3)
Medical abortion regimens
- 5.
  There is limited evidence regarding teratogenicity of mifepristone, but overall the risk appears to be low. (Level III)
- 6.
  Misoprostol is a known teratogen when used in the first trimester of a pregnancy. (Level II-2)
- 7.
  The risk of teratogenicity is high with the use of methotrexate. (Level II-3)
- 8.
  Oral mifepristone 200 mg and buccal misoprostol 800 μg is 95% to 98% effective up to 49 days after last menstrual period. The risk of ongoing pregnancy is less than 1%. (Level I)
- 9.
  Oral mifepristone 200 mg and buccal, vaginal, or sublingual misoprostol 800 μg is 87% to 98% effective up to 63 days after last menstrual period. The risk of ongoing pregnancy is less than 3.5%. (Level I)
- 10.
  Intramuscular/oral methotrexate and vaginal/buccal misoprostol is 84% to 97% effective up to 63 days after last menstrual period. The risk of ongoing pregnancy is 0.4% to 4.3%. (Level I)
Providing medical abortion
- 11.
  There is no evidence to support or refute the routine administration of Rh immunoglobulin to Rh negative women who undergo medical abortion before 49 days last menstrual period. (Level III)
- 12.
  There is no strong evidence supporting routine antibiotic prophylaxis for medical abortion. (Level II-2)
- 13.
  Medical abortion is associated with bleeding, which is often heavier than a menstrual period, and with potentially severe cramping. (Level III)
- 14.
  Prophylactic ibuprofen administration does not provide superior pain control compared with as-needed dosing in women undergoing medical abortion. (Level I)
Post-abortion care
- 15.
  Follow-up rates are similar for both remote and in-clinic visits. (Level II-2)
- 16.
  When both women and their clinician believe successful expulsion has taken place, based on history alone, complete abortion is likely. (Level II-2)
- 17.
  Either ultrasound and/or serial bhCG measurements provide definitive evidence of pregnancy termination. (Level I)
- 18.
  A fall of beta human chorionic gonadotropin levels of 80% or more from pre-treatment to first follow-up at 7 to 14 days is indicative of a completed medical abortion. (Level II-2)
- 19.
  If ultrasound is used to assess completion of a medical abortion, endometrial thickness alone is not predictive of the need for subsequent surgical intervention. (Level II-2)
- 20.
  Retained products of conception requiring aspiration are more common in medical compared with surgical abortion. (Level II-2)
- 21.
  A second dose of misoprostol may lead to completion of a medical abortion when there is a retained gestational sac or an ongoing pregnancy. (Level III)
- 22.
  Severe complications following medical abortion are rare. (Level II-2)
- 23.
  Ovulation may occur as soon as 8 days after starting the medical abortion procedure. (Level III)
- 24.
  Insertion of intrauterine device at the follow-up visit after medical abortion is associated with higher insertion rates and equivalent expulsion rates compared with delayed insertion. (Level I)
Introduction
- 1.
  Women who are eligible for medical abortion should be counselled on the availability of both medical and surgical options. (Level II-2A)
Pre-procedure care
- 2.
  When communicating with a woman who has an unintended pregnancy, health care providers should use appropriate nonjudgemental and nondirective language, preferably with additional written or online material, and should ensure a confidential environment. (Level III-A)
- 3.
  Health care providers uncomfortable with abortion counselling or provision must promptly refer the woman to another health care provider/facility or provide information on where she may be able to access abortion care. (Level III-A)
- 4.
  Women seeking an abortion should have the capacity to provide voluntary informed consent. Health care providers should counsel women on the proposed intervention and alternatives, outcomes, and risks. (Level III-A)
- 5.
  Providers should use a reliable method to confirm that a pregnancy is at appropriate gestational age for effective and safe medical abortion. (Level II-2A)
- 6.
  Women should be informed that medical abortion carries a small increased risk of additional intervention compared with surgical abortion. (Level II-2B)
Medical abortion regimens
- 7.
  Only evidence-based regimens should be used to perform medical abortion. (Level I-A)
- 8.
  Mifepristone 200 mg oral and misoprostol 800 μg buccal/vaginal/sublingual is the regimen of choice for medical abortion up to 70 days among eligible women. (Level I-A)
Providing medical abortion
- 9.
  Rh immunoglobulin is recommended to Rh negative women undergoing medical abortion beyond 49 days from last menstrual period and may be offered before 49 days. (Level III-C)
- 10.
  Women who have risk factors for ectopic pregnancy and/or clinical symptoms, such as abdominal pain and vaginal bleeding, should have an ultrasound and be adequately followed. (Level III-A)
- 11.
  Women who have a pregnancy of unknown location and request medical abortion should receive abortion care without delay provided that they have no clinical symptoms of ectopic pregnancy (EP). If the transvaginal ultrasound demonstrates an empty uterus and the bhCG is > 2000 IU/L, the woman should be evaluated for an EP and appropriate counselling, investigations, and follow-up should be arranged. (Level III-B)
- 12.
  All women with a pregnancy of unknown location, and women who have not had a pre-abortion ultrasound, must have serial bhCG levels until ectopic pregnancy has been excluded and/or the abortion is complete. (Level III-A)
Post-abortion care
- 13.
  All women undergoing medical abortion should have a follow-up assessment to confirm completion of the abortion. (Level II-2A)
- 14.
  A reliable method of follow-up should be used. This can be done in clinic or remotely using ultrasound and/or serial bhCG measurements combined with clinical history. (Level II-2A)
- 15.
  A fall of bhCG levels of less than 80% from pre-treatment to the first follow-up at 7 to 14 days requires further investigation/management/follow-up/referral. (Level II-2A)
- 16.
  Providers should inform women about symptoms and signs of complications and give them clear information on emergency care. (Level III-A)
- 17.
  Women with ongoing pregnancy at first follow-up after the start of a medical abortion with mifepristone/misoprostol should be offered repeat misoprostol or surgical evacuation. (Level III-A)
- 18.
  Women with ongoing pregnancy 14 to 21 days after the start of a medical abortion with mifepristone/misoprostol should be offered surgical evacuation. (Level III-A)
- 19.
  Surgical abortion is recommended for women with ongoing pregnancy after methotrexate/misoprostol for attempted medical abortion. (Level III-A)
- 20.
  If a woman wishes to start a hormonal method of contraception, it should be started as soon as possible after taking misoprostol. (Level III-B)
- 21.
  If a woman wishes to start using an intrauterine device, it should be inserted at the follow-up visit after medical abortion, once completion of the abortion is confirmed. (Level I-B)

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^☆: From Planned Parenthood of Houston and Southeast Texas^aand the Department of Obstetrics and Gynecology, Baylor College of Medicine.^b

^☆☆: Reprint requests: Jerry Edwards, MD, Planned Parenthood of Houston and Southeast Texas, 3601 Fannin, Houston, TX 77004.

^★: 0002-9378/97 $5.00 + 06/1/80932

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New technologies permit safe abortion at less than six weeks' gestation and provide timely detection of ectopic gestation☆,☆☆,★

Abstract

Section snippets

Material and methods

Results

Comment

Am J Obstet Gynecol

Am J Obstet Gynecol

Reducing the morbidity of vacuum aspiration abortion

Int J Gynaecol Obstet

Abortions that fail

Obstet Gynecol