意外妊娠人工流产术后高效避孕措施弃用情况的调查研究

背景　流产后关爱（PAC）服务促进意外妊娠女性人工流产术后（简称术后）高效避孕措施的选择,但随访发现部分患者后期会弃用原有的高效避孕措施。目的　了解意外妊娠术后高效避孕措施弃用状况,探究弃用原因及其相关影响因素。方法　选择2019年1-12月于浙江省人民医院因意外妊娠行人工流产术且术后选择复方口服避孕药（COC）或长效可逆避孕方法（LARC）两种高效避孕措施的女性为研究对象,均给予常规PAC宣教服务。分别于术后月经来潮后第1、3、6、9、12个月进行随访,随访形式包括返诊、电话、微信等。收集意外妊娠术后高效避孕措施弃用情况及原因、弃用后的避孕措施、意外妊娠情况,并采用多因素Logistic回归分析探究意外妊娠术后弃用高效避孕措施的影响因素。结果　共346例意外妊娠女性术后接受PAC服务后落实高效避孕措施并完成随访,其中选择COC 259例（74.9%）,LARC 87例（25.1%）。意外妊娠术后月经来潮后第1、3、6、9、12个月COC弃用率为14.3%~83.4%、LARC弃用率为0~19.5%;术后各随访时间点COC弃用率随时间变化呈升高趋势（P<0.05）。弃用COC后,80.3%（208/259）的女性更换为非高效避孕措施,3.1%（8/259）的女性更换为LARC。弃用LARC后,11.5%（10/87）的女性更换为非高效避孕措施,8.0%（7/87）的女性更换为COC。术后月经来潮后第12个月,COC弃用率及更换非高效避孕措施率均高于LARC弃用率及更换非高效避孕措施率（P<0.05）。术后COC弃用的主要原因是难以坚持每天定时服药、药物不良反应及担心影响日后生育;LARC弃用的主要原因集中在放置后导致的不良反应和并发症,其次也有女性担心影响日后生育而弃用。多因素Logistic回归分析结果显示,生育史〔OR=0.492,95%CI（0.304,0.712）〕、重复流产〔OR=0.591,95%CI（0.315,0.893）〕及避孕态度〔OR=0.543,95%CI（0.246,0.912）〕是意外妊娠术后弃用原有高效避孕措施的保护因素,年龄〔OR=1.782,95%CI（1.562,3.671）〕是意外妊娠术后弃用原有高效避孕措施的危险因素（P<0.05）。结论　术后COC弃用率高,LARC相对稳定,术后女性弃用高效避孕措施的原因主要为难以坚持、药物不良反应、并发症及担心日后生育。年龄、生育史、重复流产及避孕态度是意外妊娠女性行人工流产术后弃用原有高效避孕措施的影响因素,因此,临床应根据上述特点做好术后持续个性化随访服务,以降低高效避孕措施的弃用。     

The Food and Drug Administration and medroxyprogesterone acetate. What are the issues?

In 1978, the Food and Drug Administration denied approval of the three-month injectable contraceptive depot medroxyprogesterone acetate for use in the United States. This decision goes against the advice of the FDA's own scientific advisory panels, as well as the rulings of the World Health Organization and the drug regulation institutions of more than 70 developed and developing countries. In response to protest from the manufacturer of depot medroxyprogesterone acetate and from many health professionals, the FDA took the unusual step of scheduling a public board of inquiry to review its decision in January 1983. Reviewing the scientific literature on the risks and benefits of depot medroxyprogesterone acetate, we find no reason to deny depot medroxyprogesterone acetate approval, provided that studies of its possible side effects are continued and that women use it only after having made an informed choice between this and other methods of contraception.     

高危人工流产后及时口服避孕药妈富隆的临床观察

目的:探讨早孕合并高危因素的人群在人工流产后及时口服避孕药妈富隆的临床效果。方法:将400例研究对象随机分为两组,自愿接受手术后立即口服避孕药妈富隆者纳入观察组(200例),术后不采取避孕措施者纳入对照组(200例)。观察两组人工流产术后出血量、出血时间、术后21 d子宫内膜以及月经恢复情况、避孕效果及用药不良反应情况。结果:观察组出血量少,出血时间短,流产后子宫内膜及月经恢复快,月经周期规律,与对照组比较差异有统计学意义(P<0.05),观察组无痛经及盆腔炎病例,且药物不良反应轻,避孕效果优于对照组(P<0.05)。结论:高危人工流产后立即口服避孕药妈富隆,能减少术后并发症,有利于身心健康的恢复和避孕措施的落实,符合生殖健康理念,是PAC服务的一项重要内容,值得临床推广应用。     

The relationship of tubal infertility to barrier method and oral contraceptive use

We studied past contraceptive use in 283 nulliparous infertile women who had a diagnosis of tubal adhesions or occlusion and in 3833 women admitted for delivery at seven collaborating hospitals from 1981 to 1983. The relative risk of tubal infertility associated with barrier contraceptive use or oral contraceptive use was calculated using multivariate logistic regression to control for confounding by region, age, religion, education, smoking, number of sexual partners, time since menarche, and use of other contraceptive methods. Women who had ever used barrier methods of contraception were at a significantly decreased risk of tubal infertility (relative risk = 0.6; 95% confidence limits, 0.5 and 0.8). When type of barrier method used for the longest time was evaluated, those who used the diaphragm or condoms plus spermicides were at lower risk than those who used condoms or spermicides alone. Overall, past use of oral contraceptives neither increased nor decreased a woman's risk of tubal infertility, but there was evidence that the association between oral contraceptives and tubal infertility may vary by the amount of estrogen and type of progestogen in the oral contraceptive used. We conclude that contraceptive users who use barrier methods that combine both a mechanical and chemical barrier, such as diaphragms, cervical caps, and condoms plus spermicides, have the clearest protection against tubal damage.     

Vitamin A,pregnancy, and oral contraceptives

It has been shown that women receiving oral contraceptives have increased levels of serum vitamin A. High vitamin A levels may constitute a teratogenic hazard. Women who conceive soon after discontinuing oral contraceptive therapy may be especially at risk to this hazard. An increase in vitamin A levels in women taking oral contraceptives has been confirmed. During early pregnancy there is no significant difference in vitamin A levels between women who have recently been taking oral contraceptives and those who have not. The authors were not able to demonstrate that either taking oral contraceptives shortly before pregnancy or a high vitamin A level during the first trimester of pregnancy, comparable to that of a woman taking oral contraceptives, has any detrimental effect on the outcome of pregnancy. It seems unlikely that women conceiving soon after discontinuing oral contraceptive, has any detrimental effect on the outcome of pregnancy. It seems unlikely that women conceiving soon after discontinuing oral contraceptive therapy run any teratogenic risk from increased vitamin A levels.     

Sexual, reproductive and contraceptive risk factors for carcinoma-in-situ of the uterine cervix in Sydney

Sexual, reproductive and contraceptive risk factors were investigated in a matched community-based case-control study of carcinoma-in-situ of the uterine cervix in Sydney. The risk was related strongly to the number of sexual partners: women who had had seven or more sexual partners in a lifetime had a six-fold increased risk compared with those with one or no partner. Early age at first sexual intercourse was also a risk factor, but this effect was reduced substantially after adjustment for the number of partners, with only a two-fold excess risk persisting for those with first intercourse before the age of 16 years as compared with those whose first sexual intercourse was at the age of 25 years or later. The long-term use of oral contraceptive agents was associated with an elevated risk (relative risk, 2.3 for more than six years of use); this effect was maintained for both oestrogen and progestogen doses. The risk increased with the number of induced abortions that had been undergone (relative risk, 2.2 for two or more abortions), but this effect was not statistically significant. A protective effect was found for women who had had a tubal ligation, for those who practised the rhythm method of birth control, and for women who breastfed. It is possible that these reduced risks may relate to unmeasured variables of life-style.     

Injectable contraception

When deciding on the choice of a contraceptive, it is necessary to determine whether the method is to be permanent or reversible. If permanent, then the menstrual irregularities, the weight gain, headaches and subjective side effects of depot medroxyprogesterone acetate (DMPA) would suggest that it is not the most appropriate contraceptive for use up to the onset of menopause. Indeed there would be difficulty, given the frequent incidence of amenorrhea, in determining when this had occurred. If the contraception required is to be reversible, then it would be essential to inform the women that, provided she is of proven fertility, her chance of becoming pregnant after the use of DMPA is severely limited for 12 months after her last injection, and that she will have a conception rate of 75% by 15 months and 95% by 24 months. Very few women planning further pregnancies would tolerate that sort of delay in return of fertility, which makes the reliable spacing of their pregnancies impossible. DMPA seems not be the most appropriate agent for permanent contraception, for nulliparous women, for lactating women, or for women planning to space their pregnancies as accurately as possible. Sensitive discussion and accurate information on the advantages, disadvantages and relative reliability of all the available methods of contraception (hormonal, chemical, mechanical, barrier, and natural methods) should enable the woman, in consultation with her sexual partner and her medical practitioner, to choose the method most appropriate to her current and future needs. On the basis of the most recent information about DMPA, it is doubtful that DMPA will ever be the most appropriate choice.     

Depo-Provera--ethical issues in its testing and distribution.

Ethical issues relating to the use of the injectable contraceptive in developed and developing countries alike involve public policy decisions concerning both criteria for testing a new drug and individual choices about using a specific form of contraception approved for national distribution. Drug testing consists of an important but still evolving set of procedures. Depo-Provera is not qualitatively different from any other drug and some unpredictable risks are inevitable, even after extensive animal experiments and clinical trials. In assessing the risks and benefits of Depo-Provera use, epidemiological data from large-scale human use is now beginning to become more important than data from animal experiments and clinical trials. The consumer's best interest is central to any ethically responsible system of drug distribution. Systems of informed choice are needed, even in societies where illiteracy remains common and medical services are weak. In the case of a contraceptive, the risks of non-use leading to unintended pregnancy, which can result in high mortality, are relevant as well as the side-effects of the method. An attempt, therefore, is made here to categorise those issues which are universal and those which are country-specific.     

Digoxin in heart failure and cardiac arrhythmias

HEART FAILURE: Digoxin therapy has no effect on mortality in heart failure. Digoxin may be useful for maintaining clinical stability and exercise capacity in patients with symptomatic heart failure. Digoxin appears to be of most benefit in patients with severe heart failure, cardiomegaly and a third heart sound. Digoxin should be used as a second-line drug after diuretics, angiotensin-converting enzyme inhibitors and beta-blockers in patients with congestive heart failure who are in sinus rhythm. Digoxin should be used as a first-line drug in patients with congestive heart failure who are in atrial fibrillation. ARRHYTHMIAS: Digoxin has a limited, but useful, role, either alone or in combination with other agents such as beta-blockers, diltiazem or verapamil, in achieving satisfactory resting ventricular rate control in patients with chronic atrial fibrillation. In patients who lead a predominantly sedentary lifestyle (perhaps particularly in those who are elderly), digoxin alone may be the agent of choice.     

The effect of low-oestrogen combined pill, progestogen-only pill and medroxyprogesterone acetate on oral glucose tolerance test

The effect of a low-oestrogen combined pill, progestogen-only pill and medroxyprogesterone acetate on oral glucose tolerance test was studied in 29, 30 and 9 indigenous Kenyan women respectively. Glucose tolerance test was performed before treatment was started and then after 1,3 and 6 months in microgynon users. The mean areas under the glucose curves were also significantly elevated. Significant increase in blood glucose values were noted only at 30 minutes after 6 months of use of the progestogen-only oral contraceptive but the mean blood glucose values were higher than in the control after 1,3 and 6 months of use. However, the mean values of the areas under the glucose curves were significantly elevated after 1,3, and 6 months of use. Medroxyprogesterone acetate users showed significantly lower fasting blood glucose values at 60 and 90 minutes after 1 month of use, after which the blood glucose values returned to the pre-treatment values. The mean values of the glucose curve areas showed no significant change. It is concluded that both microgynon and minipill cause relative impairment of glucose tolerance test as early as after 1 month of use. Medroxyprogesterone acetate does not impair oral glucose tolerance for at least the first 6 months of use. The implications of these findings are discussed.     

A case-control study of breast cancer in relation to the use of steroid contraceptive agents

In a case-control study of 141 cases of breast cancer and 279 control patients from the Royal Prince Alfred and Westmead Hospitals during 1980-1982, we found similar risk factors to those reported for other populations. There was no statistically significant evidence of an increased risk of cancer from the use of oral contraceptive agents; the crude estimate of relative risk for patients who had used oral contraceptive agents at some time was 1.3 with 95% confidence limits of 0.8 and 1.9. After adjustment for other risk factors (age at first live birth, age at menarche, number of pregnancies, menopausal status, bilateral oophorectomy and years of education), the estimate of the relative risk of ever having used an oral contraceptive agent was 0.9 with 95% confidence limits of 0.6 and 1.5. Further analysis in terms of duration of use and dosage also provided no evidence of an increased risk.     

Effects of steroidal contraceptives on gallbladder: a review

In regard to gallbladder disease and oral contraceptive use, more than ten controlled epidemiologic studies have been reported and reviewed in this paper. The findings presented concerning the association of oral contraceptive use with the development of a gallbladder disease are contradictory. Oral contraceptive use and use of estrogens in postmenopausal women have been reported to be associated with increased attack-rates of a gallbladder disease, but the increased risk is found higher in those using estrogens than progestin based oral contraceptives. Other studies, however, have reported little overall effect of oral contraceptive use on the risk of the gallbladder disease. Where increased risk has been documented, this has been more related to duration than overall. The increased risk of oral contraceptive use to gallbladder disease has been observed higher in the 6-12 months of usage. Only one study has reported increased risk of gallbladder disease in long-term users. The increased gallbladder disease in oral contraceptive users may be greater in multiparae than in nulliparae; pregnancy and obesity may also pose an increased risk to the disease in oral contraceptive users. However, these findings are not widely accepted.     

LOCAL TREATMENT OF TRACHOMA WITH SULFANILAMIDE WITH SPECIAL REFERENCE TO ITS CONCENTRATION IN THE AQUEOUS HUMOR*

Since the publication of the brief report by Heineman (1) on the original use of sulfanilamide in the treatment of trachoma followed shortly by that of more extensive studies of Loe (4a), and Lian (3a), a large number of articles on the same subject have appeared in medical literature. The authors have not been unammous in their opinions in regard to the degree of effectiveness of the drug on trachoma. They may be generally divided into three groups: First, those (2) who con- sider sulfanilamide as of doubtful or of no value at all in the treatment of trachoma; second, those (3) who consider sulfanilamide only as a useful adjunct to the usual local trachoma treatment; (To them. sulfanilamide alone does not cause healing. But it becomes an effec tive agent when used together with other chemical or mechanical measures) snd finally, those (4) who have obtained more or less con- sistently good results with the use of sulfanilamide alone.     

Decreased risk of symptomatic chlamydial pelvic inflammatory disease associated with oral contraceptive use

Studies have shown that oral contraceptive use may protect against pelvic inflammatory disease (PID), but it is not known whether oral contraceptives protect against the disease among women already infected with Chlamydia trachomatis or Neisseria gonorrhoeae. The relationship between oral contraceptive use and PID was analyzed in a case-control study of 141 women with verified PID and 739 randomly selected, sexually active women with no clinical evidence of the disease. Case and control subjects were stratified on the basis of infection with C trachomatis, N gonorrhoeae, or neither organism. Among women infected with C trachomatis alone, those with PID were less likely than control subjects to use oral contraceptives. The association was significant when oral contraceptive use was compared with nonuse (odds ratio, 0.22; 95% confidence interval, 0.08 to 0.64) and with noncontraception (odds ratio, 0.17; 95% confidence interval, 0.06 to 0.53) and remained so after adjusting for potential confounding variables by logistic regression analysis. Among women infected with N gonorrhoeae alone, no association was found between use of oral contraceptives and PID. These data suggest that oral contraceptive use protects against symptomatic PID among women infected with C trachomatis but not among those infected with N gonorrhoeae.     

长效氯醚避孕针对家兔慢性毒性的实验研究

研究结果表明:①氯醚避孕针长期使用对家兔体重增长无影响。②各组动物实验前后血常规检查,结果均在正常值范围内,未见外周血中白细胞总数及其分类的异常改变。③各项生化指标检查,可见给药组血清GPT活性在9个月以内有升高(P<0.01),但随继续用药逐渐恢复正常,肝脏排泄机能、肾功能及血糖、血清蛋白、血脂等无明显影响。④各组动物尿常规检查未见异常改变。以上结果提示,长效氯醚避孕针长期应用,对家兔重要器官的机能无明显毒性作用。     

A field study of Depo-Provera: its use as a contraceptive method by women in a rural town in West Malaysia from February 1968 to December 1969

To determine the acceptability, practicability, and popularity of Depo-Provera as an additional contraceptive method to be offered by the National Family Planning Board NFPB of Malaysia, 550 patients of Sungai Besar, Malaysia, who accepted the Depo-Provera injection method from the start of the injection program, February 23, 1968, until the cutoff date of December 31, 1969, were studied. At the cutoff date, 318 (58%) were still receiving regular injections at 3-month intervals. The remaining 232 women discontinued use of the injection. Of those who discontinued use, 176 (32%) were interviewed, while the other 56 women were lost to follow-up, due mainly to migration. Assuming that 1 injection would protect a woman from getting pregnant for a 3-month period, the retention rates at the end of 12 and 24 months were 63% and 41%. These continuation rates were fairly high and were as good as those for the oral pill, which is the main contraceptive method provided since the beginning of the operational service program of the NFPB in May 1967. Except for a small number of Indian women with a high rate of discontinuation there was not much difference in continuing the method between the Malays (60%) and the Chinese (56%). The younger age group of women seemed to have a higher proportion of discontinuation. The findings showed that amenorrhea (35%)most bothered the women who discontinued the injection method. Irregular bleeding (20%) and other medical side effects (11%) were the other main complaints that caused women to discontinue using the injection as a contraceptive method. It was concluded that Depo-Provera (150 mg) injected once every 3 months appears to be simple, acceptable, popular, and effective as a contraceptive method among women in a rural town in Malaysia.     

Combined Oral Contraceptive Pills: Profile of Acceptors in a Tertiary Hospital in South-South Nigeria

BACKGROUND: Combined oral contraceptive pills were the first contraceptive method to provide sexual freedom of choice for women through reliable, personal and private control of fertility. They are the most widely used hormonal contraceptives and also the most popular non-surgical method of contraception. OBJECTIVE: To review the profile of acceptors of combined oral contraceptive pills at the University of Uyo Teaching Hospital, Uyo. METHODOLOGY: An 8 year review of all clients that accepted combined oral contraceptive pills in the family planning clinic. RESULTS: There were 1,146 new contraceptive acceptors during the period of study out of which 309 (27.9%) accepted the pills. Majority of the clients were between 20 and 29 years of age (54.0%), were multiparous (72.8%), Christians (99.7%) and 61.2% had tertiary level education. Two hundred and fifty-five women (82.5%) desired to use combined oral contraceptive pills to space births while 7.8% wanted to limit child bearing. There was a high discontinuation rate among the women (45.0%) and out of these 87.9% of the clients changed to other contraceptive methods. All the clients commenced their pills within seven days of menstruation and only the low dose monophasic preparations were available in the family planning unit and thus were given to the clients. CONCLUSION: Women who accept to initiate combined oral contraceptive pills in our center are young, well educated, multiparous women who want to space their pregnancies. However, due to the high discontinuation rate among the clients, there is need for further studies evaluating reasons for the high discontinuation rate, exploring interactions between clients and providers' and also providers' attitude towards combined pills in our environment.     

Is oral contraceptive therapy advisable in woman with family history of breast cancer?

A 20-year-old single woman suffers from severe dysmenorrhea, unresponsive to analgesic medication. Findings for gynecological examination were normal. Her mother died of mammary cancer at the age of 47. This cancer was diagnosed at age 42 while she was taking oral contraceptives. The patient in question, and her 3 sisters, had been warned against taking oral contraceptives. Now it is suggested that her dysmenorrhea might respond to contraceptive therapy. The question is asked regarding the use of oral contraceptives. In response, a diagnostic laparoscopy is recommended to determine if endometriosis is present. If endometriosis is found, medroxyprogesterone acetate may be used for suppression of ovulation, but ovulation may continue to be suppressed for 12-18 months after discontinuing this medication. Danazol is also effective in treating endometriosis and dysmenorrhea but has no estrogenic effect. Available data do not show an increased incidence of mammary cancer in users of oral contraceptives.     

Association between oral contraceptives and myocardial infarction. A review

Analysis of the association between oral contraceptive use and the development of myocardial infarction in women less than 50 years of age shows that cigarette smoking is the most important factor in increasing the likelihood of myocardial infarction. This effect is independent of oral contraceptive use but oral contraceptive use also appears to be a risk factor; however, their use in the absence of other predisposing factors appears to have only a small effect on increasing the risk of dying from myocardial infarction. This small increase is of the same order of magnitude as the increased risk of death from thromboembolic disease. Oral contraceptive users more than 30 years of age who have other factors that increase the likelihood of myocardial infarction appear to have a substantially higher death rate.     

Barrier contraceptive methods and preeclampsia

Recent investigations have suggested that women who use barrier methods of contraception may be at increased risk for preeclampsia. We used data from two prospective pregnancy studies to examine the relationship between contraceptive use before conception and preeclampsia. The preeclampsia rates among women using barrier contraceptives were not significantly higher than the rates in women using nonbarrier contraceptives or the rates in women using no contraceptives in either study. The odds ratios for preeclampsia in barrier contraceptive users in the two studies were 0.89 (95% confidence interval [Cl], 0.71 to 1.12) and 0.85 (95% Cl, 0.49 to 1.45) compared with nonbarrier contraceptive users and 0.91 (95% Cl, 0.71 to 1.16) and 0.81 (95% Cl, 0.48 to 1.35) compared with women using no contraceptives. After adjusting for other risk factors, we found no association between preeclampsia and barrier contraceptive use. Additional studies are needed to resolve this issue; however, we would recommend that women not be advised to avoid barrier contraceptives unless more data linking their use to preeclampsia appear.