Anticipated Pain During Intrauterine Device Insertion

Study ObjectiveTo identify predictors of anticipated pain with intrauterine device (IUD) insertion in adolescents and young women.DesignWe performed linear regression to identify demographic, sexual/gynecologic history, and mood covariates associated with anticipated pain using a visual analogue scale pain score collected as part of a single-blind randomized trial of women who received a 13.5-mg levonorgestrel IUD.SettingThree academic family planning clinics in Philadelphia Pennsylvania.ParticipantsNinety-three adolescents and young adult women aged 14-22 years.InterventionParticipants received either a 1% lidocaine or sham paracervical block.Main Outcome MeasuresAnticipated pain measured using a visual analogue scale before and perceived pain at 6 time points during the IUD insertion procedure.ResultsBlack or African American participants had a median anticipated pain score of 68 (interquartile range [IQR], 52-83), White participants had a median anticipated pain of 51 (IQR, 35-68), whereas participants of other races had a median anticipated pain score of 64 (IQR, 36-73); P = .012. In multivariate analysis, race was the only covariate that significantly predicted anticipated pain at IUD insertion. Women with anticipated pain scores above the median had significantly higher perceived pain during all timepoints of the IUD insertion procedure.ConclusionIncreased anticipated pain is associated with increased perceived pain with IUD insertion. Black adolescent women experience greater anticipated pain with IUD insertion. This population might benefit from counseling and clinical measures to reduce this barrier to IUD use.     

Immediate Postpartum Contraception: Intrauterine Device Insertion

Insertion of an intrauterine device (IUD) in the immediate postpartum period is a safe, evidence‐based form of contraception appropriate for most women. Despite the higher risk of expulsion as compared with interval insertion, the benefits of insertion in the immediate postpartum period are significant and include improved rates of contraception continuance and reduced instances of short interval birth. Through shared decision making, midwives and other clinicians can assist women in clarifying their reproductive goals and understanding of contraceptive options, including this method. In response to identified gaps in knowledge and insertion technique among midwives, this article provides an overview of immediate postpartum IUD insertion, risks and benefits, and eligibility criteria and describes preinsertion, insertion, and postinsertion care.     

Insertion and removal of Implanon®: practical considerations

ABSTRACT

Implanon®, a novel contraceptive implant containing the progestogen, etonogestrel (68 mg), provides highly effective, well-tolerated contraception for up to 3 years. Its single-rod design, semi-rigid polymer base and convenient pre-loaded presentation mean that Implanon® has potential insertion and removal advantages over the six-capsule Norplant® implant. Insertion of Implanon® is simple: the applicator needle is positioned subdermally and the cannula is withdrawn, leaving the implant rod in place. Implanon® is removed using the ‘pop out’ technique, involving a 2-mm incision. A meta-analysis of data from seven open-label, randomized studies in 1378 women compared the ease of insertion and removal of the Implanon® and Norplant® implants and the frequency of associated complications. It was approximately four times quicker to insert and remove Implanon® than Norplant® (mean insertion times 1.1 vs. 4.3 min, respectively; mean removal times 2.6 vs. 10.2 min, respectively). Insertion complications were very rare with both Implanon® (0.3%) and Norplant® (0.0%). However, Implanon® was associated with a significantly lower frequency of removal complications (0.2 vs. 4.8% with Norplant®; p < 0.001). Implant site abnormalities were uncommon. The simplicity of the insertion and removal procedures with Implanon® may have significant implications for contraceptive implant training programs and user counselling.     

Pelvic Actinomycosis Following Insertion of an Intrauterine Contraceptive Device

Summary: A case of actinomycosis following insertion of an intrauterine contraceptive device is reported. The patient was treated successfully by antibiotic therapy and conservative surgery.     

Insertion of a Permanent Electrode for Intractable Detrusor Instability

EDITORIAL COMMENT: We accepted this case report for publication because of the miseries or urinary incontinence in elderly women, and because this problem is so common. Any method of cure or control merits consideration. Also urinary incontinence is often the reason why women with their intellectual facilities apparently intact become institutionalized. The woman portrayed in this report was made of stern stuff So too were her medical attendants, since urinary incontinence resulting from a motor vehicle accident (details of injuries not provided) would be treated by conservative means alone by many practitioners, including the writer of this comment, who would have prescribed the vaginal application of dienoestrol cream, which improves symptoms in many women with urinary incontinence and renders other therapies unnecessary in some (A). In less than 2 years this woman was investigated and treated with urodynamic study x 4, drug regimens x 5 and surgical procedures x 4. The takeaway message is that her urinary incontinence was controlled.
(A) Beischer N A, Grant FT. Management of gynaecological disorders in older women. Update in Geriatric Medicine. Part 2. Merck Sharp and Dohme University Program for General Practitioners pl-12.     

Outcome of the Laparoscopic Two-Team Sling Procedure,Tension-Free Vaginal Tape Insertion,and Transobturator Tape Insertion in Women With Recurrent Stress Urinary Incontinence

ObjectiveAlthough the surgical treatment of primary stress urinary incontinence (SUI) has been well studied, the optimal treatment of persistent or recurrent SUI represents a significant challenge to the surgeon, and there are limited relevant published data. The aim of this study was to document outcome data for various surgical techniques used at our centre for the treatment of recurrent SUI, and to assess the immediate and long-term complications associated with these procedures.MethodsThis retrospective study assessed the outcome of the laparoscopic two-team sling procedure, tension-free vaginal tape (TVT) insertion, and transobturator tape (TOT) insertion in the treatment of recurrent SUI in women. Data collected included patient demographics, urodynamic data, postoperative subjective cure and objective cure (negative cough stress test), and intraoperative and postoperative complications.ResultsForty-six women with recurrent SUI were included in the study: 24 had had laparoscopic two-team sling procedures, 15 had had TVT insertion, and 7 had had TOT insertion. For each procedure, objective cure rates were 91.7%, 73.3%, and 85.7%, respectively, and subjective cure rates were 79.2%, 60%, and 57.1% respectively. In the laparoscopic two-team sling group, one woman developed an infected hematoma and one required surgery for a small bowel obstruction.ConclusionThe laparoscopic two-team sling procedure or TVT or TOT insertion may be used in experienced hands for surgical management of patients with recurrent stress urinary incontinence. We found no statistically significant differences in outcomes between the three groups, possibly because of the small sample size. Larger sample size and longer follow-up within prospective randomized trials are warranted to identify any possible differences.     

Insertion of IUD after extrauterine mislocation of the previous one

We present a case report of a 37-year-old woman with accidental finding of two IUDs--one inserted correctly and the other one located in the abdomen.     

Serial Transvaginal Ultrasonography Following McDonald Cerclage and Repeat Suture Insertion

Summary: The aim of this study was to explore the hypothesis that serial transvaginal ultrasonography identifies early evidence of suture failure and that repeat cerclage delays delivery. We undertook a review of our policy of transvaginal ultrasonographic cervical surveillance after McDonald cerclage and of repeat suture insertion if persistent cervical effacement developed. Data from 26 pregnancies in 26 women are analyzed. The women had had a total of 57 mid-trimester miscarriages with a median of 2 (1–6) mid-trimester losses per woman. Twelve (46%) of the 26 women developed cervical changes at scan and underwent repeat cerclage. All 14 women who had a single suture inserted progressed to live births but 1 of the 13 women who had repeat cerclage had a mid-trimester miscarriage (p<0.05). The median gestation at delivery for the women who had repeat cerclage was 35 (22–39) weeks compared with 38 (36–40) weeks for those who had a single suture (p>0.05). The median interval from the detection of cervical changes at scan to delivery was 13 (4–19) weeks. Serial transvaginal ultrasonography after cervical cerclage identifies a group of women who are more likely to deliver preterm, and provides an opportunity for intervention (repeat cerclage) which appears to delay delivery by an average of 7 weeks.     

Insertion forces with intrauterine devices: implications for uterine perforation

The force required to insert a Copper 7, Multiload Copper or Nova T IUD was measured in 197 successful and 25 unsuccessful insertion attempts. These forces were compared with the forces required to perforate freshly obtained uterine specimens with a metal uterine sound and Dalkon shield device, as well as with the clinically tested devices. The mean insertion forces for the Copper 7, Nova T and Multiload Copper devices were 1.502 N, 2.134 N and 4.041 N respectively, while the mean insertion pressures (N/mm2) were 0.203, 0.209 and 0.122 respectively. The mean in vitro fundal perforation forces with metal sounds was 20.7 N and with the Dalkon shield 31.6 N. The Copper 7, Multiload Copper and Nova T IUDs achieved mean in vitro forces of 5.75 N, 9.2 and 8.1 N respectively, without causing perforation. Primary uterine perforation at the time of insertion of these devices appears unlikely.     

Serial Transvaginal Ultrasonography Following McDonald Cerclage and Repeat Suture Insertion

Summary: The aim of this study was to explore the hypothesis that serial transvaginal ultrasonography identifies early evidence of suture failure and that repeat cerclage delays delivery. We undertook a review of our policy of transvaginal ultrasonographic cervical surveillance after McDonald cerclage and of repeat suture insertion if persistent cervical effacement developed. Data from 26 pregnancies in 26 women are analyzed. The women had had a total of 57 mid-trimester miscarriages with a median of 2 (1–6) mid-trimester losses per woman. Twelve (46%) of the 26 women developed cervical changes at scan and underwent repeat cerclage. All 14 women who had a single suture inserted progressed to live births but 1 of the 13 women who had repeat cerclage had a mid-trimester miscarriage (p>0.05). The median gestation at delivery for the women who had repeat cerclage was 35 (22–39) weeks compared with 38 (36–40) weeks for those who had a single suture (p>0.05). The median interval from the detection of cervical changes at scan to delivery was 13 (4–19) weeks. Serial transvaginal ultrasonography after cervical cerclage identifies a group of women who are more likely to deliver preterm, and provides an opportunity for intervention (repeat cerclage) which appears to delay delivery by an average of 7 weeks.     

Insertion of mirena after endometrial resection in patients with adenomyosis

STUDY OBJECTIVE: To evaluate the efficacy of Mirena, a levonorgestrel-releasing intrauterine device, after endometrial resection for treatment of menorrhagia caused by adenomyosis. DESIGN: Open, randomized, observational study (Canadian Task Force classification II-2). SETTING: Private hospital. PATIENTS: Ninety-five women. INTERVENTION: Endometrial resection, after which control patients received no further treatment and study patients had Mirena inserted immediately after the procedure. MEASUREMENTS AND MAIN RESULTS: The rate of amenorrhea after 1 year was significantly higher in the Mirena group. Nineteen percent of women in the control group had a second procedure to control bleeding compared with none in the Mirena group. CONCLUSION: Insertion of Mirena after endometrial resection is effective treatment for menorrhagia caused by adenomyosis and has very few adverse effects.     

Predicting the Insertion Length for Gastric Tube Placement in Neonates

ObjectiveTo compare error rates of three existing methods of predicting the gastric tube insertion length in a group of neonates <1 month corrected age: age‐related, height‐based (ARHB); direct distance nose‐ear‐xiphoid (NEX); and direct distance nose‐ear‐mid‐umbilicus (NEMU).DesignRandomized controlled trial.SettingFive neonatal care units in a large midwestern city.ParticipantsOne hundred and seventy‐three hospitalized neonates.MethodsNeonates were randomly assigned to one of three groups: ARHB, NEX, or NEMU. For primary analysis, only tubes placed too high with the tube tip in the esophagus or at the gastroesophageal junction were considered to be misplaced. For secondary analysis, a stricter definition was used, and low placements (pylorus or duodenum) were also considered to be misplaced. All radiographs were blinded and read by a pediatric radiologist.ResultsFor the primary analysis, the differences in percentages of correctly placed tubes among the three methods was statistically significant (χ²=34.45; p<.0001), with NEMU and ARHB more accurate than NEX (NEMU χ²=18.59, p<.0001; ARHB χ²=21.34, p<.0001). Using the stricter definition for placement, ARHB was not significantly different from NEX (p=.0615). A new ARHB equation was developed specific for neonates <1 month corrected age.ConclusionsDirect distance nose‐ear‐xiphoid should no longer be used as an nasogastric/orogastric (NG/OG) tube insertion‐length predictor in neonates. Either NEMU for NG/OG tubes or the new ARHB equation for NG tubes should be used.