Use of prescription contraceptive methods in the UK general population: a primary care study.

OBJECTIVE: To determine prescription contraceptive use in the UK. DESIGN: Observational study using a primary care database. SETTING: The Health Improvement Network (THIN). POPULATION: Women in THIN aged 12-49 years in 2008, registered with their primary care doctor for at least 5 years, and with a prescription history of at least 1 year were included. METHODS: THIN was searched using the Read and MULTILEX codes for the following methods: combined oral contraceptives (COCs), progestogen-only pills (POPs), copper intrauterine devices (Cu-IUDs), the levonorgestrel-releasing intrauterine system (LNG-IUS), progestogen-only implants, progestogen-only injections, and contraceptive patches. MAIN OUTCOME MEASURES: Prevalence, switching, and duration of prescriptions. RESULTS: A cohort of 194 054 women was identified. The prevalence of contraceptive use was: COCs, 16.2% (95% confidence interval, 95% CI 16.1-16.3%); POPs, 5.6% (95% CI 5.5-5.6%); Cu-IUD, 4.5% (95% CI 4.4-4.5%); LNG-IUS, 4.2% (95% CI 4.1-4.2%); progestogen-only implants, 1.5% (95% CI 1.5-1.6%); progestogen-only injections, 2.4% (95% CI 2.3-2.4%); and contraceptive patches, 0.1% (95% CI 0.1-0.2%). Within 1 year, 9.8% of new COC users switched to alternative COCs, and 9.0% changed to a different method. Among new COC users who did not switch method, 34.8% did not continue use beyond 3 months, and were no longer using a prescription contraceptive. CONCLUSIONS: Among users of oral contraceptives who did not switch method, over one-third did not continue use beyond 3 months. This supports current UK guidelines recommending a follow-up consultation with a healthcare professional 3 months after the first prescription of COCs.

Effective treatment of heavy and/or prolonged menstrual bleeding with an oral contraceptive containing estradiol valerate and dienogest: a randomized, double-blind Phase III trial.

BACKGROUND: This double-blind trial investigated the efficacy and safety of estradiol valerate/dienogest (E(2)V/DNG) for the treatment of heavy menstrual bleeding without recognizable organic pathology. METHODS: Otherwise healthy women with idiopathic heavy, prolonged or frequent menstrual bleeding, confirmed during a 90-day run-in phase, were randomized (2:1) according to a permuted-block, computer-generated schedule to E(2)V/DNG or placebo for 196 days at 34 centres in Europe and Australia. The primary efficacy end-point was the proportion of women with a 'complete' response (i.e. a return to 'menstrual normality') during a 90-day efficacy phase. Secondary end-points included changes in measured menstrual blood loss (MBL) and iron metabolism parameters. RESULTS: The intention-to-treat population comprised 231 women. The E(2)V/DNG response rate was much higher than with placebo (P < 0.0001). The mean reduction in MBL volume in E(2)V/DNG recipients was 69.4% (median 79.2%) versus 5.8% (median 7.4%) in placebo recipients. The between-treatment difference in MBL volume was 373 ml in favour of E(2)V/DNG (95% confidence interval 490, 255 ml; P < 0.0001). Significant improvements in iron metabolism parameters were observed with E(2)V/DNG but not placebo. Overall, 14 women (9.7%) treated with E(2)V/DNG and 5 (6.2%) treated with placebo prematurely discontinued treatment because of adverse events, headache being the most prevalent. Serious adverse events occurred in both the E(2)V/DNG and placebo groups (each n = 2). CONCLUSIONS: E(2)V/DNG is an effective treatment in women with heavy and/or prolonged menstrual bleeding without organic pathology. Further study of E(2)V/DNG compared with an active comparator is warranted. ClinicalTrials.gov identifier: NCT00307801.

Increased cardiac atrial-to-ventricular length ratio in the fetal four-chamber view: a new marker for atrioventricular septal defects.

OBJECTIVES: Atrioventricular septal defects (AVSDs) are the most common cardiac abnormality in fetuses with numerical chromosomal aberrations, in particular trisomy 21. The majority of AVSDs are not detected by routine ultrasound examination in pregnancy. We report two simple cardiac measurements that may substantially improve antenatal detection of AVSDs. METHODS: Cross-sectional ultrasound images through the fetal thorax demonstrating the four-chamber plane of the heart were obtained in 123 normal fetuses between 10 and 38 weeks of gestation. Heart length was measured at the level of interventricular septum by placing the calipers on the epicardium at the apex of the heart and on the endocardium at the top of the atrium. Ventricular length was measured by shifting the atrial caliper to the crossing point of the ventricular septum and mitral valve. Atrial length was calculated as the difference between the heart length and ventricular length. Based on these measurements, the atrial-to-ventricular length (AVL) ratio was calculated. Data were compared to measurements from 29 consecutive fetuses with AVSD between 13 and 39 weeks of gestation. RESULTS: In normal fetuses, the AVL ratio did not change with gestation and the mean AVL ratio was 0.47 (95% prediction interval 0.35 to 0.63). In the AVSD group, the mean AVL ratio was 0.77 (range, 0.59-0.99). If a cut-off value for the AVL ratio of 0.6 was chosen, the detection rate of AVSD was 86.2% at a 5.7% false-positive rate. For a 100% detection rate, the false-positive rate was 7.3%. CONCLUSIONS: The AVL ratio can accurately discriminate between hearts with AVSDs and normal cardiac anatomy. Incorporation of the AVL ratio measurement into routine antenatal ultrasonography may substantially improve the ability to diagnose AVSDs antenatally.

Prenatal diagnosis of 22q11 microdeletion in an early second-trimester fetus with conotruncal anomaly presenting with increased nuchal translucency and bilateral intracardiac echogenic foci.

We report on a 16-week fetus, in which detection of increased nuchal translucency thickness and bilateral intracardiac echogenic foci led to the prenatal diagnosis of truncus arteriosus communis, interruption of the aortic arch and aplastic thymus. Cytogenetic examination confirmed a 22q11.2 microdeletion consistent with the suspected CATCH 22 syndrome. Subsequently hydrops fetalis developed and the fetus died in utero at 18 weeks. This case report supports the hypothesis that both cardiac failure and left ventricular outflow tract obstruction may cause increased nuchal translucency thickness. The association between increased nuchal translucency thickness and CATCH 22 syndrome should be considered in diagnostic procedures. The sonographic diagnosis of both increased nuchal translucency thickness and intracardiac echogenic foci requires specialist ultrasonography and echocardiography. In particular, identification of right-sided or bilateral echogenic foci should prompt further detailed examination.

Fetal pulmonary venous flow pattern is determined by left atrial pressure: report of two cases of left heart hypoplasia, one with patent and the other with closed interatrial communication.

We report two cases of fetal left heart hypoplasia with extremes of size of interatrial communication, i.e. a closed foramen ovale and an atrial septal defect. Doppler examinations of the pulmonary veins showed almost to and fro flow in the fetus with the closed foramen ovale and, in contrast, a normal flow velocity waveform in the fetus with the atrial septal defect, despite mitral atresia. Our observations support the importance of left atrial pressure in the creation of a pulmonary venous flow pattern in the fetus.

Longitudinal observation of deterioration of Doppler parameters, computerized cardiotocogram and clinical course in a fetus with growth restriction.

We report on a fetus with intrauterine growth restriction detected at 27 weeks' gestation, who was longitudinally followed up until delivery by cesarean section 33 days later (31 + 5 weeks) due to severe decelerations in CTG. Longitudinal Doppler assessment of the umbilical artery (UA), the middle cerebral artery (MCA) and the main branch of the right pulmonary artery (RPA), the ductus venosus (DV) and the left coronary artery was compared to clinical course and computerized CTG. At first presentation (day--33) increased resistance in both the UA and uterine arteries with bilateral notches was found. Absent enddiastolic flow (AED) in the UA was found at day--19 and reverse flow (RED) at day--11. The MCA showed a decreased pulsatility first at day--19 and again at day--11 together with RED in the UA. The RPA initially (day--33) showed increased PI which returned to normal values at day--19 but increased again at day--1, when the DV showed RED and the coronary arteries became visible. The DV was normal until day--11, then its PI began to increase together with occurence of RED in the UA, but reverse flow in the DV occurred only on the eve (day--1) of severe decelerations in CTG. Short-term variability in computerized CTG was stable at 6 to 7 ms, except for an intermediate drop to 4 ms at day--10. Maternal hypertension was found at day--19 and mild preeclampsia developed at day--12. A reduction of fetal movements was noticed at day--5. This report shows that at 29 weeks gestation despite detection of AED resp. RED in the UA a prolongation of pregnancy for 19 resp. 11 days is possible. In addition to abnormal CTG, late signs of fetal deterioration are reverse flow in the DV and visibility of the coronary arteries. The role of increased resistance in the main branches of the pulmonary arteries should be examined in the future.