Oral steroidal contraception: scientific basis and recent development.

PIP: Modern medicine 1st made the oral contraceptive (OC), a combined OC, available to women in 1960, and much progress in improving OCs and reducing risks associated with them has occurred. Approximately 200 million women have used OCs worldwide and about 60 million women are currently using this contraceptive method. OCs are efficacious because the hormones in the OCs alter the physiology of the hypothalamo-pituitary-ovarian/uterine axis at 6 sites, e.g., altering the endometrium so implantation of the blastocyst cannot occur. Despite the effectiveness of OCs (virtually 100% effective) in comparison with other contraceptive methods, they often cause side effects and complications. Some side effects and complications from estrogen and predominantly estrogen OCs include vomiting, hypertension, and venous thrombosis/pulmonary embolism. Possible progestogen and predominatly progestogen OC side effects and complications are leucorrhea, urinary tract infections, epilepsy aggravation, and cholestatic jaundice. In addition, pregnancy, venous thromboembolism, heart disease, and malignancies of the breast and genital tract are absolute contraindications to OCs. On the other hand, OCs provide health benefits, in addition to preventing unwanted pregnancies, such as lowered incidence of pelvic inflammatory disease, acne improvement, and protection against endometrial carcinoma and ovarian epithelial neoplasia. In order to ensure that health benefits of OCs are maximized and the risks minimized, family planning practitioners worldwide must monitor OC users for side effects. Recent OC formulations now include the progestogen only OCs, multiphase OCs, low dose OC called gestodene, and the "morning after pill".^ieng

Closed mitral valvotomy in pregnancy--a Malaysian experience.

Our experience from 1968 to 1985 in 12 women requiring closed mitral valvotomy during pregnancy is reviewed. All patients had severe mitral stenosis and were in functional class 3 (2 patients) or class 4 (10 patients). Mitral valvotomy was performed between the 18th and the 30th week of pregnancy using a transventricular dilator. Improvement in functional class was noted in all patients postoperatively. One patient had postvalvotomy mitral regurgitation and heart failure, which responded to diuretics; the subsequent course was uneventful. Eleven patients had normal deliveries; whilst one patient had a Caesarean section for an obstetric indication. All babies were normal and there was no maternal death. This series confirms that closed mitral valvotomy can be performed with an acceptable degree of safety during pregnancy, when indicated.

Intestinal obstruction following previous myomectomy and the use of beta-sympathomimetics in pregnancy.

Two cases of intestinal obstruction in pregnancy following previous myomectomy are reported. The use of tocolytic agents to suppress premature uterine contractions may be a predisposing factor and probably intensifies the obstruction. As the symptoms mimic the normal side-effects of pregnancy, the diagnosis is often delayed. Laparotomy was done, as initial conservative treatment was unsuccessful in both instances. A live baby was delivered in the first case, whilst the second case ended in an abortion.

Illegal abortion: an attempt to assess its cost to the health services and its incidence in the community.

This article describes a study designed to test a method for assessing the cost to the health services of illegally induced abortion and the feasibility of estimating the incidence of induced abortion by a field interviewing approach. The participating centers included three hospitals in Ankara, Turkey; three hospitals in Ibadan, Nigeria; one hospital in Caracas and one in Valencia, Venezuela; and two hospitals in Kuala Lumpur, Malaysia. Hospitalized abortion cases were classified as induced or spontaneous or as "probably induced," "possibly induced," or "unknown" according to a classification scheme comprising certain medical criteria. The sociodemographic characteristics of induced and spontaneous abortion cases were subjected to discriminant function analysis and the discriminating variables best characterizing the induced versus the spontaneous abortion groups were identified for each center. On the basis of this analysis, the "probably" and "possibly" induced and "unknown" categories were further classified as induced or spontaneous abortion, with stated probabilities. Thus an overall estimate is made of the proportion of all hospitalized abortions that can be considered illegally induced outside the hospital. Selected results on costs of induced and spontaneous abortion are shown. The method further tested the feasibility of obtaining valid survey data on abortion from the communities studied by re-interviewing the women hospitalized for induced and spontaneous abortion six months later in their homes. This exercise showed a degree of under-reporting of abortion that varied widely among centers, even among women who had admitted illegal induction at the time of hospitalization. The feasibility of estimating the incidence of illegal abortion by field studies is discussed in the light of these findings.

Ovarian pregnancy--a case report.

PIP: This article describes a case of ovarian pregnancy without the presence of an IUD. The patient, a 33-year old Indian woman para 4, presented with right iliac fossa pain and 8 weeks of amenorrhea. There was no history of contraceptive use. The initial diagnosis was twisted ovarian cyst; however, ultrasonography revealed an enlarged uterus with a gestational sac. At laparotomy, a right solid ovarian mass was found anterior to the uterus and adherent to the uterus, bladder, and the rectosigmoid junction. The mass was mobilized and a right salpingo-oophorectomy was performed along with left ovarian cystectomy and tubal ligation. Microscopic examination indicated a developing embryo of 6 weeks gestation. Ovarian pregnancy has been reported in 1/10,000-40,000 pregnancies and represents 0.5-2.0% of all ectopic pregnancies. 12-20% of ectopic pregnancies in the presence of an IUD are ovarian as are 0.5% of all pregnancies occurring in IUD users. It is speculated that, in this case, fertilization took place outside the ovary and reimplantation occurred. Diagnosis of ovarian pregnancy generally requires 4 criteria: 1) the tube on the affected side must be intact; 2) the fetal sac must occupy the normal position of the ovary; 3) the ovary and sac must be connected to the uterus by the utero-ovarian ligament; and 4) definite ovarian tissue must be present in the sac wall.^ieng

A multicenter randomized comparative investigation of ML Cu250, TCu-220C and Cu7 IUDs.

The final analysis of 1725 interval insertions of the 3 IUDs is presented. The earlier observations were confirmed at: at 24 months, no significant differences were found between the TCu-220C and ML Cu250 IUDs though the TCu-220C had a lower gross pregnancy rate (2.0 versus 2.9) and the ML Cu250 had a lower expulsion rate (2.3 versus 4.1). Expulsions were more common with the Cu7 when compared to the ML Cu250 (p 0.001) and T-220C (p 0.01); pregnancy rates were also higher with p values of 0.05 and 0.01 respectively. Other use-related terminations were not significantly different among the 3 IUDs and continuation rates at 24 months were: Cu7, 69, TCu-220C, 73, and ML Cu250, 74.

The acceptability of the Copper 7, Multiload 250 and Copper T 220C intrauterine devices.

PIP: 1725 patients were recruited for a prospective, randomized, comparative study of 3 IUDs: the Gravigard (Cu 7), Copper T 220C (T Cu 220C), and the Multiload 250 (ML Cu 250). All 3 devices were acceptable to patients with a continuation rate of over 60% at 2 years. The rates for accidental pregnancy and expulsion at 2 years were significantly higher for the Cu 7 when compared with the ML Cu 250 (P0.05) and the T Cu 220C (P0.01). Use-related terminations were more common with the Cu 7 than the ML Cu 250 (P0.05). All but 1 of the physicians questioned felt that the ML Cu 250 gave the least problems at insertion.^ieng

Timing of antenatal tetanus immunization for effective protection of the neonate.

PIP: The relationship between the timing of maternal tetanus toxoid immunization and the presence of protective antitoxin in placental cord blood was investigated among women admitted to the obstetrical service of the University Hospital in Kuala Lumpur, Malaysia. The 1st dose was given between 13-39 weeks of gestation, with a median of 29 weeks. The 2nd dose was given an average of 4 weeks later. Protection was conferred on 80% or more of newborns whose mothers received their 1st tetanus toxoid injection 60 days or more before delivery. Protective levels were seen in all cord blood samples from infants whose mothers had received their 1st injection 90 days before delivery. Similarly,protective titers were found in 100% of cord blood samples when the 2nd maternal injection was give 60 days or more before delivery. There was no significant degree of protection when immunization was carried out less than 20 days before delivery. A single-dose schedule provided no protection when less than 70 days before delivery. Cord and maternal antiotoxin titers differed by no more than 1 2-fold dilution for almost all of the individual paired sera. A cord: maternal antitoxin ratio of 2 was more likely to occur with increasing time between the 2nd injection and delivery. Overall, these findings indicate that the 1st injection of a 2-dose maternal tetanus toxoid schedule should be given at least 60 days and preferably 90 days before delivery.^ieng

A randomised comparative evaluation of the copper 7, multiload copper 250 and T copper-22OC IUDs.

Two new Cu-IUDs, the TCu-22OC and Multiload Cu250, were evaluated against the Cu7 in 1,199 subjects in a randomised, multicentric trial using a common study protocol. During the 2 years following insertion, cumulative first-segment rates for total use-related terminations showed no significant differences between the 3 devices; however, the Cu7 had a significantly higher termination rate for accidental pregnancy compared to the TCu-22OC and its expulsion rate was significantly higher than the ML Cu250. The rate of accidental pregnancy was higher and the expulsion rate lower with the ML Cu250 compared to the TCu-22OC but these differences were not significant. The results are discussed in relation to IUD design and their application in family planning.

Uterine perforation by the intra-uterine device.

PIP: The article presents 5 cases of IUD translocation in women aged 27-34; 3 of the devices were Copper-7; the others were a Copper-T and Lippes Loop. In all cases the devices' strings were missing and the devices had been localized through X-rays and sometimes through a hystero-salpingogram. The devices were removed by laparoscopy in 3 cases, and by laparotomy in 2 cases. IUD translocation is usually secondary to uterine perforation which occurs at the time of insertion, as in the cases presented here. The incidence of translocation depends on the time of insertion, the technique of insertion used, and, especially, the skill of the person performing the procedure. Modern methods of diagnosis of a translocated IUD include ultrasonography, hysterography, and hysteroscopy. All translocated devices should be removed even though they are asymptomatic.^ieng

A study of menstrual patterns following laparoscopic sterilization with silastic rings.

The menstrual patterns of 281 women undergoing laparoscopic sterilization with silastic rings were studied prospectively. A significant increase in dysmenorrhea and irregular periods was seen soon after sterilization but this was transient, returning to presterilization levels by 12 months. Menorrhagia was not observed and the amount of menstrual blood loss showed a trend towards normal following sterilization. No permanent adverse effects on menstrual patterns were seen in the 1st year after sterilization. It is suggested that factors other than the sterilization procedure may be responsible for the high prevalence of menstrual dysfunction that has been reported following sterilization.