Contraceptive practice after women have undergone "spontaneous" abortion in Indonesia and Sudan

Studies of hospitalized "spontaneous" abortion patients in two Muslim countries (Indonesia and Sudan) revealed the need for contraception in this group of married women and indicated the potential role of maternity hospitals in providing them with contraceptive counseling. It could not be determined which of the abortions were induced outside the hospital and which were truly spontaneous. Of the 893 women treated at the Djakarta Hospital, 15.3% used contraceptives during the month of conception of the index abortion, compared to 10.0% of the 2 759 patients in Khartoum. After hospitalization for completion of the abortion, the rates of contraceptive use increased by more than one third in both cities. The highest rates of increase in contraceptive use after abortion were noted among poorly educated women, women with large families, and women with abortions diagnosed as septic. Among the nonseptic patients at all hospitals, those experiencing complications associated with the abortion reported a slightly higher rate of postabortion contraceptive use. In hospitals where contraceptive counseling was provided, there was a proportional increase in postabortion use of contraceptives by the study population.     

Oral hypoglycemic agents and the pregnant diabetic: "from bench to bedside"

Today, the criteria for diagnosis and treatment have evolved into an evidence-based medicine approach. The need for evidence-based information is especially critical in the management of gestational diabetes, in general, and especially in the use of oral hypoglycemic agents. These agents have been categorically contraindicated for decades in the United States based on anecdotal and/or weak evidence for these recommendations. In this article, the similarities between gestational and type 2 diabetes are described and the rationale for the use of oral hypoglycemic agents for the treatment of both are discussed. The author will show how research from basic sciences (placental transfers) to clinical studies (perinatal outcome) can lead to significant evidence on which to base management recommendations.     

"No party hat, no party": successful condom use in sex work in Mexico and the Dominican Republic

Sex workers and their clients are particularly vulnerable to HIV/STI transmission. Most research on condom use has focused on barriers preventing use; less is known about attitudes, motivations and strategies employed by those who feel positively about condoms and who use them successfully. For this qualitative study, we conducted focus group discussions with sex workers (14), both female and transvestite, in Ciudad Juarez, Mexico, and female sex workers (17) and male clients (11) in Santo Domingo, Dominican Republic, who identified themselves as successful condom users in a condom use questionnaire. Discussions explored definitions of successful condom use, motivations and strategies for condom use and messages for future condom promotion. Sex workers defined successful condom use as being in agreement with their clients and partners about using condoms, protecting themselves from disease and unwanted pregnancy, and feeling good about using condoms. Condoms were seen to be hygienic, offer protection and provide a sense of security and peace of mind. Specific strategies included always having condoms on hand, stressing the positive aspects of condoms and eroticising condom use. Future educational messages should emphasise condom use to protect loved ones, increase security and pleasure during sex, and demonstrate respect for both sex workers, clients and partners.     

Hawaiian-style "Talkstory": Psychosocial Assessment and Intervention During and After Pregnancy

Standard health care services generally limit the psychosocial assessment and management provided for women during and after pregnancy. Recommendations for improving prenatal care include the need for evaluating different approaches for addressing culturally sensitive care. In an innovative prenatal and postpartum program developed by public health nurses in Hawaii, the use of local "talkstory" has been integrated successfully as a caregiving strategy for participating women from Asian and Pacific Islander ethnic groups. This article describes the use of talkstory for delivering psychosocial care and its application in the design of health care services for pregnant women in the general population.     

Human fibroblasts produce "pregnancy-specific" beta-1 glycoprotein in vitro.

Normal and genetic variant strains of nonmalignant human fibroblasts produce in vitro a substance indistinguishable from the recently described "pregnancy-specific" beta-1 glycoprotein (PSbetaG, PAPP-C, SP1). Demonstration of this presumed placenta-specific material in a nonplacental site raises questions about its normal physiologic role and use as a cancer marker.     

"Principles and practice of hysteroscopy"

In recent years the hysteroscopic method of examination has not become as widespread as we hoped. Its field of indication has not yet been clearly defined. In the diagnostic field hysteroscopy has not yet been utilized to the full. Colpo-hysteroscopy or contact hysteroscopy will possibly open up new opportunities for its use.     

Associations between "early" red blood cell transfusion and severe intraventricular hemorrhage, and between "late" red blood cell transfusion and necrotizing enterocolitis

Transfusion of banked donor erythrocytes can be life saving for small and ill neonates with severe anemia or active hemorrhage. However, risks of transfusions exist and must be weighed against potential benefits each time a transfusion is considered. The present review seeks to bring together the published data supporting 2 newly postulated risks of transfusions among very low-birth-weight neonates. The first is an association between "early" red blood cell transfusions, those administered in the first few days after birth, and the subsequent occurrence of a grade 3 or 4 intraventricular hemorrhage. The second is an association between "late" RBC transfusions and the subsequent occurrence of necrotizing enterocolitis. Much remains to be discovered about the pathogenetic links between transfusion and these adverse outcomes. Moreover, work is needed to clearly establish whether transfusions are causatively associated with these adverse outcomes or are covariables. The purpose of this chapter is to review the associations between transfusion and intraventricular hemorrhage and between transfusions and necrotizing enterocolitis and to use these associations to hypothesize that evidence-based improvements in transfusion practice have the potential to improve neonatal intensive care unit outcomes.     

Comparison of "instrument-associated" and "spontaneous" obstetric depressed skull fractures in a cohort of 68 neonates

OBJECTIVE: A depressed skull fracture is an inward buckling of the calvarial bones and is referred to as a "ping-pong" fracture. This study aimed to look at differences between "spontaneous" and "instrument-associated" depressed skull fractures. STUDY DESIGN: This retrospective, case-control analysis included every neonate who was admitted with a depressed skull fracture between 1990 and 2000. Cases after a spontaneous vaginal delivery, elective cesarean delivery, or cesarean delivery that was performed during labor without previous instrument use were classified as "spontaneous" (n = 18 cases). Cases after a delivery in which forceps or a vacuum cup had been used either successfully or unsuccessfully were classified as "instrument-associated" (n = 50 cases). Continuous data were analyzed with 2-tailed unpaired t tests; chi 2 analysis was used for nominal data. A probability value of <.05 was considered statistically significant. RESULTS: Fifty depressed skull fractures were associated with an instrument delivery, and 18 depressed skull fractures were classified as "spontaneous." The only obstetric parameter that differed significantly between the 2 groups was the length of the active phase. Among the 68 neonates, 15 neonates underwent prolonged second stage, forceps or manual head rotation, or forceps use during elective cesarean delivery. All "instrument-associated" cases were caused by forceps application or sequential instrument use; depressed skull fractures never occurred after isolated vacuum extraction. Every type of forceps was involved. Intracranial lesions were significantly more frequent in the instrument-associated group (30% vs 0%; P = .02). Two infants sustained persistent severe motor disabilities. CONCLUSION: Depressed skull fractures occur in the setting of spontaneous and operative deliveries, although the incidence is higher in the latter case. Depressed skull fractures that are associated with instrumental deliveries are significantly more likely to be associated with intracranial lesions. Persistent disabilities are rare.     

The first year of clinical experience with concurrent post abortal insertion of copper "T" 200

Immediate postabortion period is a strategic time for providing contraceptive protection, especially insertion of IUD concommitent with the abortion procedure. One can be reasonably safe in assuming that copper T 200 may be used with comparable degrees of clinical effectiveness in such situations. A higher incidence of IUD removals for bleeding and IUD displacements in the postabortal insertion is justifiable when it is considered that a greater number of women are reached and thus protected against the risks of an unwanted pregnancy. Major problems such as cervical or uterine perforations were not associated with this type of insertion. IUD removal was effected in 5.39% for bleeding, and in 4.69% of cases where there was either complete or incomplete expulsion of the device. Expulsion rate was high within the 1st week of insertion, and it is reasonable to believe that abortion complications were responsible for this high expulsion rate. Even though IUD removal was not required, about 15% of the patients had menstrual irregularities at the end of 1 year of use. Embedding of the copper device did not pose any problem for removal of the device after 1 year of use and no fragmentation of copper wire was found in the IUDs removed. In those who wanted, conception had occurred within 4 months of removal of the device. The follow-up data suggests that the use-effectiveness of the device gradually increase with the duration of use and is found to be highest after 1 year of use.     

More than just vaginal intercourse: anal intercourse and condom use patterns in the context of "main" and "casual" sexual relationships among urban minority adolescent females

PURPOSE: Receptive anal intercourse has long been recognized as a risk factor for the transmission of HIV and STIs. Most HIV/STI prevention messages continue to emphasize penile-vaginal transmission, so many teens do not recognize anal intercourse as risky sexual behavior. This purpose of this study was to determine the prevalence of anal intercourse, and to describe the relationship between types of sexual relationships (main vs. casual), types of sexual behaviors (vaginal vs. anal sex), and types of contraception used among inner-city sexually experienced adolescents. METHODS: Reproductive health histories were obtained from 350 sexually experienced adolescent females aged 12-18 years participating in a 5-year STI acquisition study at an urban health center. Baseline sexual behavior data was analyzed and described using frequencies, percentages and chi-square tests. RESULTS: 41% of teens and 86.5% of teens reported engaging in sexual activity with casual and main partners respectively. Sixteen percent of teens with main partners and 12% of those with casual partners engaged in receptive anal intercourse (P = 0.31). Condom use is more prevalent for both vaginal (61% vs. 32.4%, P < or = 0.0001) and anal (47.1% vs. 21.3%, P = 0.0428) intercourse in the context of casual as compared to main sexual relationships. Teens involved in a casual relationship were more likely to use anal intercourse as a form of contraception (41.2% vs. 8.5%, P = 0.0022). CONCLUSION: It is imperative that health care providers recognize that adolescents engage in anal sex, specifically inquire about their types of sexual behavior and types of sexual relationships so that anticipatory guidance regarding HIV/STI transmission risk reduction education can be tailored to meet their needs.     

Instrumental extraction in 2002 in the "AURORE" hospital network: incidence and serious neonatal complications

OBJECTIVES: The purpose of this study was to evaluate the incidence of forceps and vacuum application and the incidence of its related neonatal complications. This study was performed in a network of 37 maternity hospitals. PATIENTS AND METHOD: A postal questionnaire was sent to 156 obstetricians between February and March 2003. RESULTS: Response rate was 78%. In 2002 the operative vaginal delivery rate was 11.2% of all live births. Forceps are the primary instruments (6.3%) whereas vacuum delivery rate was 4.9%. One obstetrician never uses forceps while 38 (31%) never use vacuum. Only 29 (24%) report using both instruments frequently. During 2002 no neonatal death related to an operative vaginal delivery was reported while 145 neonatal complications were (3.2%). Major complications were one depressed skull fracture (1/4589) and 14 extensive caput succedaneum (14/4589). Minor complications were cutaneous lesions (124/4589) and facial palsy (6/4589). Vacuum delivery was associated with a significantly higher extensive caput succedaneum rate (P = 0.018) while the only depressed skull fracture observed was related to forceps use. Forceps delivery was associated with a significantly higher cutaneous lesions rate (P < 0.001). DISCUSSION AND CONCLUSIONS: This study showed that, in 2002, operative vaginal deliveries still represent a significant amount of vaginal deliveries, a majority of obstetricians do not use both instrument and neonatal associated complications are frequent (3.2%) but rarely severe. Therefore, we believe that every method that allows a safe teaching of operative delivery should be promoted.     

Fallopian tube cancer: radical surgery, extended field radiation and chemotherapy in 24 personal cases treated with "intent to cure"

This may be the largest personal experience of this rare cancer reported to date. Results with an aggressive multi-modality approach exceed results in low stage disease compared to recently reported series. Of the total of 53 personal cases treated, this report focuses on the 24 where, irrespective of clinical stage, all gross disease could be excised, and therapy then added for occult disease control. The author's evolving experience suggests that the use of aggressive and complete bulk-reductive surgery followed by both chemotherapy and extended field radiation therapy may offer a therapeutic advantage in the management of this rare disease.     

Comment: "Analysis of and reflections on some abortion request statistics" (letter)

The author of an article previously appearing in this journal attempted to evaluate the "practical efficacy" of different contraceptive methods, taking failures due to faulty use into account through a study of women requesting abortions. The work suffered from at least 2 major methodological errors: 1) the statistics on the contraceptive practices of women requesting abortions were compared with national statistics on contraceptive practices and not with statistics on the population at risk of requesting abortions at the author's medical practice. The fact that the sample of women requesting abortion was 1/3 foreign and 11% West Indian suggests doubt that their practices would be comparable to those of the national sample. 2) A less trivial error was that the authors combined figures for all women requesting abortions with all women accidentally becoming pregnant, tacitly assuming that the proportion of women translating an undesired pregnancy into a request for abortion is the same for users of all contraceptive methods. As every clinician knows, this is a false assumption: users of withdrawal, for example, are more likely to accept an unwanted pregnancy than are users of pills. The result would be overestimation of failure rates of more effective methods and underestimation of failure rates of less effective methods. The case illustrates the problem of presenting statistical and epidemiological work done by practitioners who lack the competencies required. Repeated exposure to erroneous use of statistics may tend to increase skepticism of other practitioners at any statistical evidence, even the most valid. The authors of the original article, responding to the criticisms, suggest that the findings of statistical studies are not always relevant to everyday practice, that the work was intended to provoke reflection on the unfavorable attitudes of practitioners to local contraceptive methods, and that another study on a similar topic will involve consultations with statisticians.     

Origin and goals of the "Gender Symmetry" Workshop

This article provides a brief account of the historical background to the Gender Symmetry Workshop and describes its major goals. The Workshop is a successor to an earlier workshop co-sponsored by the Centers for Disease Control and Prevention and the National Institute of Justice in 1998, namely the Workshop on Building Data Systems for Monitoring and Responding to Violence Against Women. Some key issues that were left unresolved in that workshop provided the rationale for holding the Gender Symmetry Workshop. The Workshop was designed to cover three topic areas: (1) a typology of violence, (2) measurement issues, and (3) women's use of violence.     

When adolescent girls say, "I don't know"

STUDY OBJECTIVE: To understand adolescent girls' use of "I don't know" within the context of discussing information related to sexual attitudes and behaviors. DESIGN: Qualitative analysis of seven focus groups with adolescent girls. SETTING: Urban primary care clinic. PARTICIPANTS: Adolescent girls (n = 23) with a mean age of 16.4 years (range 14 to 18 years). Fifty-two percent were African-American, 26% were Caucasian, 17% were Hispanic/Latino, and 5% were Asian. RESULTS: The use of "I don't know" served three functions: (1) place holder, (2) lack of commitment to an opinion; and (3) reduction of commitment to an opinion or belief. CONCLUSIONS: These results suggest that girls use "I don't know" when asked about their thoughts and opinions related to sexual health, and that its use can have varying implications. Discriminating the intent may help providers respond appropriately. Responses should include providing a safe and nonjudgmental environment in which girls can express their feelings and opinions regarding their sexual health.     

Liposuction for "body contouring" in gynecology

OBJECTIVES: The aim of this study was to describe the possible use of the ultrasound-assisted liposuction and liposuction with the tumescent technique for the contouring and remodelling of superficial fat areas of women in the field of gynaecology. PATIENTS AND METHODS: Between 1997 and 1999 85 healthy female patients underwent a liposuction in the department of gynaecology of the university of Essen. The patients were divided into two groups. Thirty patients (group 1) underwent an ultrasound-assisted liposuction whereas the remaining 55 patients (group 2) were operated using only the tumescent technique. RESULTS: From the operated 582 body areas a large volume liposuction with the aspiration of more than 1,000 cc fat was performed in 48.2% of the cases. In the remaining 51.8% of the cases aspiration volumes between 300 and 1,000 cc fat were obtained. No statistically significant differences could be observed when comparing the aspirat volumes between both treatment groups (p > 0.05). Serious complications were not observed. DISCUSSION: Our data could show, that liposuction is an extremely safe method for eliminating surperficial fat depots in the sense of body contouring in gynaecology, but that it should not be used for the reduction of obese body volumes. If ultrasound-assisted liposuction is really superior to liposuction with the tumescent technique remaining uncertain, no time gain could be observed due to this technique.     

Enough children: reproduction, risk and "unmet need" among people receiving antiretroviral treatment in western Uganda

In this paper, we use survey (n = 87) and interview (n = 30) data to investigate orientations towards future childbearing among people receiving antiretroviral treatment and their family members in western Uganda. We investigate how reproductive options are perceived, by those receiving treatment and those closest to them, and consider what these perceptions suggest about the existence of an "unmet need" for birth control for women with HIV. While most people say they do not wish to have more children while on treatment, this intention coexists with contradictory desires for the benefits and happiness that more children might bring. We argue that the factors influencing birth desires and outcomes are so complex and contradictory that it is virtually impossible to predict demand or uptake of birth control as more and more people with AIDS in Africa gain the ability to access antiretroviral treatment.     

A "conditionally essential" nutrient, L-carnitine, as a primary suspect in endometriosis

L-carnitine, when administered to young female mice, has been shown to induce a pathologic condition resembling human endometriosis accompanied by a marked degree of infertility. Thus, the use of this nutrient by young women may be a potential risk factor responsible for the onset of endometriosis at a later stage of their lives.     

A comparison of "hands off" versus "hands on" techniques for decreasing perineal lacerations during birth

Our goal was to determine the frequency, degree, and location of perineal lacerations and the neonatal outcomes associated with the use of two techniques of perineal protection--expectant ("hands off") and interventionist ("hands on")--during childbirth. We conducted a randomized controlled trial to compare the effectiveness of two techniques for perineum protection during spontaneous delivery. Study participants included 70 nulliparous expectant mothers, who were divided equally between the "hands off" and "hands on" groups (n = 35 per group). Perineal laceration occurred in 81.4% of the women. Among these, first-degree lacerations were predominant (82.5%). Lacerations in the anterior and posterior regions of the perineum occurred with similar frequencies. Laceration rates did not differ between the "hands off" and "hands on" groups (P > .05). Neonatal outcomes were similar in both groups. The use of "hands off" technique of perineal protection does not alter the frequency or degree of perineal lacerations in childbirth, relative to a "hands on" technique.