Ovarian function after the menarche and hormonal contraception.

The aim of the study was to determine the date of regular ovulation after the menarche to better understand the physiology of female adolescence, especially as it pertains to the use of hormonal contraception. Early morning urine samples were collected from 51 girls in the perimenarche for 9 weeks semi-annually during 2 years. Estrone- and pregnanediol-3-glucuronide values were determined. Cycles lasting 35-40 days at the onset of menses shortened to 28 days after the 23rd-25th cycle. Menses reached a 5.0-5.5 day average length at about the same time. After the 20th cycle, ovulation could be demonstrated in more than 50% of the study patients. Using a scoring system, regular ovulation could be expected on the basis of somatic data with scores of greater than 16. Hormonal contraception may be prescribed 2 years after the menarche, based on scores of greater than 16 and ovulation proven be hormonal cytology and basal body temperature.

PIP: The increasing number of pregnancies among young teenagers has drawn attention to the timing of the onset of ovulation after menarche. As part of a broader study of menstrual and ovulatory patterns at puberty, estrone and pregnanediol-3-glucuronide levels were analyzed in urine samples collected from 51 girls in the perimenarche for 9 weeks semiannually over a 2-year period. Data pertaining to changes in the menstrual cycles of these 51 girls were analyzed in the course of 30 cycles and study participants kept menstrual calendars. Cycles lasting 35-40 days at the onset of menses shortened to 28 days after the 23rd-25th cycle. Menses reached a 5.0-5.5-day average length at about the same time. The frequency of ovulatory cycles was 10-13% after the 1st 7-10 menstrual cycles; it approached 50% after the 20th cycle. The pattern of normalization of menstrual cycles in young girls is important to defining the earliest date for the need of hormonal contraception without undue risk in order to prevent early pregnancy. The findings of this study suggest that hormonal contraception can be started 2 years after the onset of menses. However, attention should also be given to somatic development. The authors have developed a scoring system which considers the state of the breasts, pubic and axillary hair, and the uterus, as well as the results of hormonal cytological analysis and basal body temperature to more accurately detect the onset of regular ovulation.

Cardiac disorders.

PIP: Most cardiovascular problems in pregnant women arise from the complications of preexisting chronic conditions (e.g., rheumatic and congenital heart disease) and hypertensive vascular disease. Regular supervision of these patients is essential to detect incipient pulmonary congestion or disturbances of cardiac rhythm. Even if the pregnancy has been uncomplicated, hospital admission 1-4 weeks before the due date is recommended to ensure optimal conditions for labor. Vaginal delivery at term with adequate sedation and use of forceps to shorten the 2nd stage of labor is the perferred mode. Induction of labor may be indicated in hypertensive vascular disease or in cases where adjusting or discontinuing drug therapy calls for precise timing of delivery. Eisenmenger's disease and primary hypertension are potential medical indications for pregnancy termination. The distribution pattern of organic heart disease encountered in pregnant women has changed in the past 20 years, with a decrease in rheumatic and an increase in congenital heart disease. The incidence of chronic rheumatic heart disease in pregnant women fell from 3.5% of all deliveries at Newcastle General Hospital in 1942-51 to 1.1% in 1962-71. Acute pulmonary edema in mitral stenosis is currently a major risk during pregnancy. There is no optimal stage of pregnancy for valvotomy, nor evidence that this procedure induces miscarriage in the early weeks. Pregnancy has become less hazardous in severe forms of congenital heart disease as more patients with these disorders have undergone cardiac surgery prior to pregnancy. Pregnancy is not believed to have any effect on the longterm course of rheumatic heart disease. Patients with aortic stenosis, coarctation of the aorta, primary pulmonary hypertension, Fallot's tetralogy, Eisenmenger's syndrome, and surgically untreated cyanotic lesions require special attention during pregnancy. The outlook for women who become pregnant after an acute cardiac infarction episode depends on the functional state of the heart at the time of pregnancy and the presence or absence of angina pain. There has been a gradual decline in perinatal mortality, especially in cases complicated by rheumatic heart disease.^ieng

Maintenance of sinus rhythm after atrial defibrillation.

The long-term results of 356 episodes of atrial defibrillation by DC shock carried out in 250 patients are reviewed. In 78 per cent of the cases, atrial fibrillation recurred by the end of 12 months in spite of the administration of quinidine or procainamide or propranolol, singly or combined. However, when no antidysrhythmic drugs were used the recurrence rate was higher at all periods of observation and 100 per cent at the end of 12 months. The difference in the overall results between the untreated group and the treated groups with the exception of the propranolol group is significant (p less than 0.05). In addition, the propranolol group showed an obviously reduced recurrence rate at 1 month, but afterwards the results tended to approximate those in the untreated group. The period during which sinus rhythm could be maintained in patients who underwent valve operations was on the whole the same as in patients who did not have heart surgery. However, in a small number of patients sinus rhythm was maintained for longer periods after mitral valve replacement than before it. Sinus rhythm was maintained for significantly longer periods when atrial fibrillation lasted less than 1 year than when it had been present for more than 1 year (p less than 0.001). It is concluded that there is justification for a judicious antidysrhythmic prophylaxis after atrial defibrillation.

A controlled trial of sotalol for 1 year after myocardial infarction.

We carried out a double-blind, randomized study, based at The Academic Department of Cardiology in Newcastle upon Tyne, to compare the effect of sotalol 320 mg once daily with that of placebo in patients from 20 hospitals who survived an acute myocardial infarction. Treatment was started 5-14 days after infarction in 1456 patients; 60% were randomized to sotalol and 40% to placebo. This represented 45% of those evaluated for entry. All patients were followed for 12 months and the analysis was done on an "intention-to-treat" principle. Sixty-four patients (7.3%) in the sotalol group died, compared with 52 (8.9%) in the placebo group. Although the mortality rate was 18% lower in the sotalol group, the difference was not statistically significant. There was a significant reduction in confirmed reinfarction, but not in all suspected reinfarctions.

Controlled trial of sotalol for one year after myocardial infarction.

In a multicentre double-blind randomised study, the effect of sotalol 320 mg once daily was compared with that of placebo in patients surviving an acute myocardial infarction. Treatment was started 5--14 days after infarction in 1456 patients (60% being randomised to sotalol, and 40% to placebo) who represented 45% of those evaluated for entry. Patients were followed for 12 months. The mortality rate was 7.3% (64 patients) in the sotalol group and 8.9% (52 patients) in the placebo group. The mortality was 18% lower in the sotalol than in the placebo group, but this difference was not statistically significant. The rate of definite myocardial reinfarction was 41% lower in the sotalol group than in the placebo group (p less than 0.05). Although the differences in mortality were not significant, this trial supports the evidence that, in the year after myocardial infarction, beta adrenoceptor blocking drugs reduce mortality by 20--25%.

Direct current shock and antidysrhythmic drugs.

A review is given of 457 episodes of atrial fibrillation that occurred in 318 patients and were treated by DC shock. Antidysrhythmic drugs, such as quinidine, procainamide, and propranolol, given singly or in combination, were used concomitantly in 389 instances, and DC shock alone was given in 68 instances. The combined effects of quinidine and DC shock, and of procainamide and DC shock were studied in the experimental animal.Combined DC shock and drug therapy gave a higher conversion rate than DC shock alone, and a statistically significant difference was found in respect of the group of patients receiving procainamide and propranolol together (p<0.01). Antidysrhythmic drugs failed on the whole to reduce the incidence of DC shock-induced dysrhythmias. However, the incidence of certain digitalis and DC shock-induced dysrhythmias was significantly less when propranolol and procainamide were given as pretreatment than when procainamide or quinidine was given alone (p<0.01). In animal experiments, quinidine had no protective action against digitalis and DC shock-induced ectopic tachycardias. Clinical and experimental observations suggest that the cardiotoxicity of these drugs may be enhanced by DC shock. Immediate or delayed post-shock rhythm disorders can be drug related and, therefore, great caution should be exercised in the use of antidysrhythmic drugs in conjunction with DC shock therapy.