Hepatitis B immunization in postpartum women.

OBJECTIVE: To investigate the acceptance and efficacy of hepatitis B immunization in women during the postpartum period. STUDY DESIGN: A group of 157 consecutive women who were delivered of neonates between 1994 and 1999 under the care of a private, full-time faculty-based practice of obstetrics and gynecology participated in the study. All patients were screened for hepatitis B surface antigen and antibody during their pregnancy. Susceptible patients eligible for hepatitis B immunization were offered the vaccine in the immediate postpartum period. The planned vaccine administration was a series of 3 intramuscular injections, with the second injection given 4 weeks later and the third given 6 months after the initial injection. Rescreening for hepatitis B surface antibody titers was performed at a visit after the last injection. Response to the immunization series was evaluated according to rate of acceptance, compliance, and achievement of seroprotection. RESULTS: Thirteen (8%) patients had been immunized previously and had antibodies, whereas 8 (5%) patients had serologic evidence of a previous infection. Of the 136 patients eligible for the study, 113 (83%) agreed to participate, 16 (12%) declined, and 7 (5%) moved away from New York right after delivery. Of the 113 participants, 104 (92%) patients received at least 2 vaccine injections, with 80 (71%) completing 3 injections. Among patients who had postvaccinal antibody titers, 66 of 69 (96%) of the group that received 3 injections and 9 (75%) of 12 of the group that received 2 injections were found to have antibodies. CONCLUSION: Hepatitis B immunization in the postpartum period is feasible and effective.

Temperature stability of vaginal specimens for Chlamydia trachomatis detection by Amplicor polymerase chain reaction assay.

Vaginal introital specimens were collected from 17 women - 10 positive and 7 negative for Chlamydia trachomatis, and kept in Amplicor collection medium at ambient temperature. Aliquots were removed at intervals for up to 34 days and frozen at -80 degrees C. Samples were thawed and assayed for C. trachomatis by polymerase chain reaction (PCR). The results of all specimens remained unchanged over this time interval.

State-mandated voluntary newborn human immunodeficiency virus screening in a New York City Hospital.

OBJECTIVE: To report the experience with state-mandated voluntary newborn human immunodeficiency virus (HIV) screening in a large university hospital. METHODS: Retrospective analysis of delivery records and newborn HIV screening data for infants born between May 4, 1996, and January 31, 1997. RESULTS: Of 3111 women, 40% had HIV testing during pregnancy, 28% had testing before pregnancy, 30% never had testing, and 2% gave no information. Most (91%) consented to postpartum newborn HIV testing, although rates varied by HIV counselor (range 81-96%, P < .001) and maternal HIV testing history (range 72-94%, P < .001). Maternal antepartum HIV testing rates varied by delivering physician (range 8-100%, P < .001) and by antepartum care site (clinics, 83%; faculty practices, 72%; private practices, 57%; P < .001). Fourteen HIV-exposed infants (0.46% of infants tested) were identified, 13 of whom were born to women known to be HIV positive before delivery. These women had received zidovudine prophylaxis according to Adult AIDS Clinical Trials Group 076 guidelines. All 14 infants subsequently tested negative for HIV. Human immunodeficiency virus-positive women were more likely than HIV-negative women to have received antepartum care in clinics (93% compared with 11%), have care paid by Medicaid (93% compared with 28%), and reside in high-risk areas (72% compared with 11%) (P < .001). CONCLUSION: Newborn HIV screening has little incremental impact in settings with aggressive antepartum screening and/or low HIV infection rates. Interventions to increase antepartum HIV screening in the private sector should be implemented.

Pelvic floor muscle surface electromyography. Reliability and clinical predictive validity.

OBJECTIVE: To study the reliability and clinical predictive validity of pelvic floor muscle surface electromyography (sEMG) for use in early detection and prophylaxis of urogynecologic disorders. STUDY DESIGN: Fifty-seven women ranging from 19 to 69 years of age completed a written questionnaire and underwent digital pelvic examination followed by pelvic floor muscle sEMG using an intravaginal sensor. Thirty-seven subjects underwent repeat evaluations one week or more later. RESULTS: sEMG data demonstrated significant test-retest reliability (P < .001) and significant clinical predictive validity (P < .05) for undifferentiated urinary incontinence, stress incontinence, urge incontinence, menstrual status and parity on both initial and repeat examinations. CONCLUSIONS: Pelvic floor muscle sEMG is reliable and consistently predictive of several important clinical status variables, suggesting that it can be a useful tool in early at-risk detection and prophylactic intervention for disorders of pelvic floor muscle laxity. Recent advances in sEMG technology make it cost-effective, convenient, noninvasive and easy to learn and administer by assisting staff. This technology is a powerful complementary tool for digital assessment of pelvic floor muscles and should be considered for use in gynecologic practice.

Simple test of pelvic muscle contraction during pelvic examination: correlation to surface electromyography.

The objective of this work was to evaluate the utility of a "Kegel" contraction test in a primary care setting. Fifty-seven adult women completed a questionnaire, underwent pelvic examination, "Kegel" assessment, and measurement of same by vaginal sensor electromyography. Thirty-seven underwent repeat evaluations within 4 weeks. Inter- and intra-rater reliability of digital scale, intra-rater reliability for sEMG measurement, correlation between raters and sEMG, and correlation between scale scores and sEMG with history and pelvic exam were determined. Fifty-six percent were pre-menopausal, 44% post-menopausal. Urinary (62%) and rectal (37%) dysfunction were reported. Inter-rater reliability, intra-observer reproducibility for both raters and sEMG measurements, and correlation between raters and sEMG were significant (P< 0.05). Comparison of continence status and digital scores showed scores

Pregnancy in the adolescent patient. Screening, diagnosis, and initial management.

Despite declines in adolescent pregnancy rates in the past decade, unplanned pregnancies among adolescents remain a significant problem in the United States. Clinicians caring for adolescents can be certain to encounter pregnancy in their patients. This article addresses surveillance and diagnosis for pregnancy in the adolescent, management, and referral of the newly-diagnosed pregnant adolescent, early pregnancy complications, common medical conditions affecting pregnancy in adolescents, and management of the postpartum and postabortal adolescent.

Long-term depot medroxyprogesterone acetate (Depo-Provera) use in inner-city adolescents.

PURPOSE: To determine Depo-Provera continuation rates and reasons for its discontinuation among adolescents. STUDY DESIGN: Medical record reviews and telephone interviews with 159 adolescents who initiated Depo-Provera use between 1 December 1992 and 31 December 1995 at two clinics in New York City. Depo-Provera continuation was measured using lifetable analysis. RESULTS: The mean age was 17.7 +/- 1.5 years, with a median of 1 pregnancy (range 0-11). Mean follow-up was 23.4 +/- 10.7 months. Depo-Provera continuation rates were 71% at 3 months, 48% at 6 months, and 27% at 12 months, and were not affected by age, race, pregnancy or contraceptive history, clinic, or foster care status. Forty-three subjects (37% of discontinuers) restarted Depo-Provera during the study period, with a mean time to restart of 8.4 months after the last Depo-Provera injection. Side effects were the main reported reason for Depo-Provera discontinuation, primarily menstrual irregularities (26%) and weight gain (18%). Seventy percent of those discontinuing Depo-Provera owing to irregular bleeding did so after only one injection. For 23%, the single reason for discontinuation was appointment noncompliance. Restart rates were lowest among those who reported irregular bleeding (15%), weight gain (9%), and hair loss (10%), and highest among those discontinuing owing to missed appointments (87%) (p < 0.05). Pregnancies occurred in 19% of Depo-Provera discontinuers. CONCLUSION: Although Depo-Provera continuation rates among adolescents are low, over a third of discontinuers may restart the method. Aggressive management of side effects and assistance with appointment follow-up may improve long-term use. High pregnancy rates warrant close follow-up after Depo-Provera discontinuation.

PIP: Depo-Provera continuation rates and reasons for discontinuation among low-income US adolescents were investigated through a review of the records of the 159 teens who initiated use of this method at two inner-city clinics in New York City, New York (US), during 1992-95. At both study sites, Depo-Provera was available as a family planning option without parental consent. Mean age of acceptors was 17.7 years, with a median of one prior pregnancy. Almost all were unmarried, Black or Hispanic, and Medicaid recipients. At follow-up (mean duration, 23.4 months), only 21 teens (13%) were still using Depo-Provera; 115 (72%) had discontinued use and the remaining 23 had been lost to follow-up. The median duration of Depo-Provera use was 6.9 months. Continuation rates were 71% at 3 months, 48% at 6 months, 27% at 12 months, and 15% at 18 months. Side effects, especially menstrual irregularities (25%) and weight gain (19%), were the main reason for Depo-Provera discontinuation. 70% of those discontinuing the method for irregular bleeding did so after only one injection. Another 23% discontinued because of problems keeping appointments. Methods adopted after Depo-Provera discontinuation included oral contraceptives (31%) and condoms (21%); pregnancies occurred in 19% of discontinuers. 43 teens (37% of discontinuers) restarted Depo-Provera during the study period, after a mean interval of 8.4 months following the last injection. Restart rates were highest among those discontinuing due to missed appointments (87%) and lowest among those reporting irregular bleeding (15%), weight gain (9%), or hair loss (10%). Recommended, to improve Depo-Provera compliance among adolescents, are strategies to motivate attendance at follow-up appointments and manage method-related side effects.

Adolescent contraception.

Adolescent pregnancy rates have declined modestly, most likely because of the increased use of condoms, especially at first intercourse. Condom distribution in schools appears to be effective in promoting condom use without increasing sexual activity. Although, to date, no contraceptive has been as effective as Norplant in reducing teen pregnancy, use of the method has declined dramatically. Depo-Provera use is increasing, but continuation rates are disappointing and the impact on teen pregnancy rates is as yet unknown. Emergency contraception remains underutilized, and interventions to improve oral contraceptive compliance are beginning to be explored. School-based programs that provide contraception without adding a strong educational component fail to improve contraceptive use or reduce pregnancy rates. Use of any contraceptive by teens is cost effective.

PIP: The high rate of adolescent pregnancy in the US is primarily reflective of nonuse or misuse of contraception. Most research in the area of adolescent pregnancy prevention has focused on programmatic issues, with little consideration of the acceptability and impact of individual contraceptive methods in an adolescent population. As adolescent use of long-acting methods and condoms (either alone or in combination with hormonal methods) increases, the impact of method choice assumes greater significance and merits serious attention. At present, 45% of US contracepting adolescents 15-19 years of age rely on the pill, 38% use condoms, 10% select injectables, 3% use implants, 4% rely on withdrawal, and 1% practice periodic abstinence. This article reviews current and potential adolescent use patterns of the major contraceptive methods: emergency contraception, oral contraceptives, condoms, Depo-Provera, the IUD, and Norplant. The reviews points to a need for more research on the management of side effects associated with adolescents' use of hormonal contraception, interventions to improve compliance with condom and pill use, and strategies to reduce the impact of misinformation provided by family and peers on risks associated with hormonal contraceptive use. Most effective in preventing teen pregnancy are likely to be multicomponent programs that encompass education, psychosocial interventions, and contraceptive provision.

Depot medroxyprogesterone acetate or oral contraception in postpartum adolescents.

OBJECTIVE: To compare rates of method continuation and repeat pregnancy among postpartum adolescents selecting depot medroxyprogesterone acetate or oral contraceptives (OCs). METHODS: A retrospective study of 161 adolescents aged 19 years and younger who gave birth at an urban teaching hospital between May 1, 1994, and April 30, 1995, returned to the hospital's family planning clinic within 14 weeks of delivery and chose depot medroxyprogesterone acetate (n=111, 69%), or OC (n=50, 31%) as their postpartum contraceptive method. Most subjects were black (99%), single (97%), and on medical assistance (85%). Data were gathered 12-18 months postpartum (mean+/-standard deviation [SD] 14.5+/-1.6 months) by telephone interview and medical record review. The main outcome measures were method continuation and repeat pregnancy. RESULTS: The mean (+/-SD) age at delivery was 17.8+/-1.4 years. Variables differentiating subjects selecting depot medroxyprogesterone acetate or OC included multiparity (34% versus 12%, P < .05), mean age at first pregnancy (15.9 versus 16.6 years, P < .05), and mean age at first delivery (16.1 versus 16.9 years, P < .05). The survival curves for depot medroxyprogesterone acetate and OC continuation differed significantly (median duration of use 8.1 versus 5.4 months, respectively), but the continuation rates at 12 months were similar (34% versus 32%). The survival curves for repeat pregnancy among subjects selecting depot medroxyprogesterone acetate differed significantly from curves of those choosing OC, with repeat pregnancy rates of 15% and 36% by 15 months. Postpartum selection of OC was the only variable entering a Cox regression model designed to predict repeat pregnancy (relative risk 3.0, 95% confidence interval 1.4, 6.7). CONCLUSION: Adolescent mothers choosing depot medroxyprogesterone acetate or OC immediately postpartum face similarly high rates of method discontinuation and repeat pregnancy within 1 year.

Use of self-collected vaginal specimens for detection of Chlamydia trachomatis infection.

OBJECTIVE: To evaluate the efficacy of a self-collected vaginal introital specimen, obtained by women using only an instruction booklet as a guide, for the detection of Chlamydia trachomatis using polymerase chain reaction (PCR). METHODS: Comparison analysis in an Urban hospital clinic, using a convenience sample of 101 women undergoing screening or treatment for C trachomatis infection. Subjects were given an illustrated instruction booklet and were asked to collect a single specimen from the vaginal introitus using the Amplicor collection kit. Cervical and introital specimens then were obtained by clinicians. The presence of C trachomatis in patient-collected versus clinician-collected samples was determined by PCR. Discordant specimens were retested by PCR, using primer pairs to the C trachomatis major outer membrane protein gene, and were screened for the presence of PCR assay inhibitors. RESULTS: Ninety-nine subjects completed the self-collection. Sixty-two percent were adolescents and 17% spoke English as their second language. Forty-three percent had never used tampons, and 36% had never looked at their own genitals. Twenty-eight cervical specimens (28%), 32 clinician-collected introital specimens (32%), and 33 self-collected introital specimens (33%) were positive for C trachomatis infection. All clinician-collected introital specimens that were positive for C trachomatis and all cervical specimens that were positive for C trachomatis were positive on self-test. Compared with clinician-collected introital specimens, self-collected specimens had a sensitivity of 100% and a specificity of 98.5%. Compared with cervical specimens, self-collected specimens had a sensitivity of 100% and a specificity of 93.4%. After discrepant analysis, self-test had a sensitivity of 100% and a specificity of 94.6% for detection of C trachomatis cervical infection. CONCLUSION: Self-collection of introital samples is both sensitive and specific in screening for C trachomatis.

Multiple gestations from in vitro fertilization: successful implantation alone is not associated with subsequent preeclampsia.

OBJECTIVE: Our purpose was to compare the risk for preeclampsia and severe preeclampsia in triplet and twin gestations and to evaluate the effect of successful implantation on the development of preeclampsia and on perinatal outcome in triplet pregnancies conceived by means of in vitro fertilization. STUDY DESIGN: A case control study was conducted of triplet pregnancies (n = 38) matched for maternal age, parity, race, and delivery date with twin pregnancies (n = 38) resulting from a single fetal reduction (spontaneously or by means of multifetal pregnancy reduction) after successful implantation of triplets. All pregnancies were conceived by means of in vitro fertilization. Rates of preeclampsia and other maternal complications, factors affecting implantation, and perinatal outcomes were compared. Preeclampsia and severe preeclampsia were defined by The American College of Obstetricians and Gynecologists criteria. The Student t test and the chi(2) test were used for statistical analysis. RESULTS: The triplet group had a higher rate of severe preeclampsia (26.3%) than the twin (reduced triplet) group (7.9%). The prevalence of preeclampsia (mild and severe combined) also was higher among the triplet group (44.7%) than among the twin group (15.8%). There was no difference in other maternal complications of pregnancy or in factors potentially affecting implantation, such as assisted hatching. Mean fetal weight was lower among the triplet group, but gestational age at delivery was not significantly different. CONCLUSIONS: The rate of preeclampsia is higher among triplets conceived by means of in vitro fertilization than among triplets conceived by means of in vitro fertilization and reduced to twins. This finding suggests that fetal number, placental mass, or factors unrelated to the success of implantation are more important to the development of preeclampsia than is successful implantation alone.

Early experience with the contraceptive use of depot medroxyprogesterone acetate in an inner-city clinic population.

There are few data on the experience of American women with the injectable depot medroxyprogesterone acetate (DMPA) since its recent approval by the Food and Drug Administration for contraceptive use in the United States. An exploratory study was conducted using chart reviews and telephone interviews of 261 women who initiated DMPA use between December 1992 and June 1994 at either a hospital-based (48%) or community-based (49%) clinic in New York City. Most DMPA users were single (70%), had had at least one birth (88%), had had at least one abortion (67%) and had ever practiced contraception (75% of those with available data). Life-table DMPA continuation rates were 63% at six months and 42% at 12 months and were not affected by the users' age, marital status, pregnancy history, clinic site or proximity of residence to the clinic. Among adults, the risk of DMPA discontinuation was highest during the three-month period following the second injection, while among adolescents, this risk increased throughout the duration of use. The most commonly reported reasons for method discontinuation were side effects, primarily menstrual irregularities (30%) and weight gain (24%).

PIP: An exploratory study of 261 US women who initiated use of depot medroxyprogesterone acetate (DMPA) between December 1992 and June 1994 at a hospital- or community-based clinic in New York City highlighted the importance of side effects to method discontinuation. The mean age of DMPA users was 25 years; 70% were unmarried and 84% were Medicaid recipients. At the time of first injection, 58% were using no contraceptive method. At telephone interview, the average time since first injection was 8.6 months. The continuation rate was 81% at 3 months, 63% at 6 months, 52% at 9 months, and 42% at 12 months. When these rates were adjusted to assume that the 37 women who were not locatable for follow-up had discontinued, they became 74%, 53%, 39%, and 30%, respectively. There was no variation in discontinuation rates on the basis of age, parity, marital status, insurance status, number of pregnancies or abortions, postpartum status, or residence. Among the 96 discontinuers for whom data were available, the most frequently cited reasons were abnormal bleeding (30%), weight gain (24%), and nausea (12%). The percentage of women with amenorrhea was 34% at 3 months, 43% at 6 months, 66% at 9 months, and 60% at 12 months. Among adults, the risk of discontinuation was highest in the 3 months after the second injection; in contrast, the risk of discontinuation among adolescents increased steadily during the first year of use. Given the strong association between DMPA side effects and discontinuation, clinic staff are urged to pursue interventions such as estrogen therapy for amenorrhea and nutrition and exercise counseling for weight gain.

Detection of Chlamydia trachomatis and Trichomonas vaginalis by polymerase chain reaction in introital specimens from pregnant women.

OBJECTIVE: We analyzed whether specimens obtained from the vaginal introitus were comparable to endocervical and posterior vaginal vault specimens for detection of Chlamydia trachomatis and Trichomonas vaginalis by polymerase chain reaction. STUDY DESIGN: Introital and endocervical specimens were obtained from 300 women at the first prenatal visit. Specimens from the posterior vaginal vault were also obtained from 219 of these patients. All samples were tested for C. trachomatis and T. vaginalis by polymerase chain reaction. RESULTS: C. trachomatis was identified in the endocervices of 36 women (12.0%); all but one of these women and none of the endocervical-negative women were positive for this organism in the introitus. T. vaginalis was detected in 22 women (10.0%); all but one were also introitus positive for this organism. Compared with endocervical and vaginal polymerase chain reaction, introital testing had a 100% specificity and a 97.2% and 95.5% sensitivity for detecting C. trachomatis and T. vaginalis, respectively. CONCLUSION: Polymerase chain reaction analysis of vaginal introital specimens is highly sensitive and specific in detecting C. trachomatis and T. vaginalis in pregnant women and thus provides an alternative to speculum examination in screening for these pathogens.

The use of levonorgestrel implants (Norplant) for contraception in adolescent mothers.

BACKGROUND: Although levonorgestrel implants (Norplant) would appear to be a good contraceptive option for adolescent mothers, there is little information about the use of Norplant in this population. METHODS: We studied 100 postpartum adolescents who chose a contraceptive method at an urban teaching hospital between September 1991 and July 1992. Structured interviews were conducted and medical records were reviewed soon after delivery and at a mean (+/- SD) of 15.5 +/- 2.9 months post partum. RESULTS: Forty-eight of the adolescent mothers chose Norplant, 50 chose oral contraceptives, and 2 (not further studied) chose barrier methods of contraception. The factors significantly associated with the choice of Norplant were older age (16.7 years among those who chose Norplant, vs. 16.2 years among those who chose oral contraceptives), multiparity (24 subjects vs. 6 subjects), and previous use of oral contraceptives (34 subjects vs. 21 subjects). During follow-up, there were no differences between the Norplant group and the oral-contraceptive group in the frequency of clinic visits (an average of 2.3 visits per subject in each group), failure to return after the postpartum visit (9 subjects vs. 11 subjects), or the incidence of sexually transmitted diseases (42 percent vs. 36 percent). At follow-up, 95 percent of the subjects in the Norplant group and 33 percent of those in the oral-contraceptive group were still using the method they had chosen (P < 0.001). During the first postpartum year 1 subject in the Norplant group and 19 in the oral-contraceptive group became pregnant (P < 0.001). Norplant users did not differ from all other adolescents studied with regard to sexual activity or condom use. CONCLUSIONS: The selection of Norplant by adolescent mothers as a method of contraception is associated with higher rates of continued use and lower rates of new pregnancy than the selection of oral contraceptives and does not affect the use of health care services, sexual activity, condom use, or the rate of sexually transmitted diseases.

PIP: Norplant would seem like a good contraceptive option for adolescent mothers, but little data exists about the use of this particular contraceptive method in that population. The authors publish findings from a prospective study to determine the factors associated with the choice of Norplant compared with other contraceptive methods and to assess the effect of Norplant on the use of health care services, sexual activity, additional pregnancy, and condom use. 100 postpartum adolescents who chose a contraceptive method at an urban teaching hospital over the period September 1991 - July 1992 were studied through structured interviews and the review of medical records soon after delivery and at a mean 15.5 months post partum. 48 of the adolescent mothers chose Norplant, 50 chose oral contraceptives, and two chose barrier methods of contraception. Norplant acceptors were of mean age 16.7 years, while oral contraceptive acceptors were of mean age 16.2 years. 24 Norplant acceptors and six oral contraceptive acceptors were multiparous, and 34 Norplant acceptors and 21 oral contraceptive users had previous experience with oral contraceptives. No differences were observed between groups during follow-up in the frequency of clinic visits, failure to return after the postpartum visit, sexual activity, condom use, or the incidence of sexually transmitted diseases. At follow-up, 95% of the subjects in the Norplant group compared to 33% of those in the oral contraceptive group were still using the method they had chosen. During the first postpartum year, one subject in the Norplant group and 19 in the oral contraceptive group became pregnant.