Oral contraceptive use and risk of endometriosis. Italian Endometriosis Study Group.

OBJECTIVE: To analyse the association between use of oral contraception and risk of pelvic endometriosis. DESIGN: We compared use of oral contraception in women with and without endometriosis. PARTICIPANTS: Eligible for the study were women with primary or secondary infertility (n = 393) or chronic pelvic pain (n = 424), requiring laparoscopy, consecutively observed between September 1995 and January 1996 in 15 obstetrics and gynaecology departments in Italy. RESULTS: Out of the 817 women included in the study, 345 had a diagnosis of endometriosis; 164 (47.5%) women with endometriosis and 139 (29.4%) without the disease reported ever using oral contraception. In comparison with never users the estimated odds ratios (OR) of endometriosis were 1.8 (95% CI 1.0-3.3) in current users and 1.6 (95% CI 1.1-2.4) in ex-users. No clear relation emerged between duration of oral contraceptive use and risk of endometriosis. In comparison with never users, the OR was 1.8 (95% CI 1.1-3.0) for women reporting their last use of oral contraception < 5 years before interview and 1.5 (95% CI 0.9-2.5) for those reporting their last use > or = 5 years before interview. CONCLUSIONS: The study suggests that oral contraception is associated with an increased risk of endometriosis but this finding is based on a selected population and cannot generalised to all women with endometriosis.     

Use of oral contraceptives and uterine fibroids: results from a case-control study

Objective To analyse the association between oral contraceptive use and the risk of uterine fibroids.
Design Participants We considered data collected in a case-control study on risk factors for uterine fibroids.
Participants We studied 843 women with uterine fibroids, whose clinical diagnosis dated back no more than two years. Controls were 1557 non-hysterectomised patients younger than 55 years admitted for acute, non-gynecological, non-hormonal, non-neoplastic conditions.
Results A total of 254 cases (30.1 %) and 360 controls (23.1 %) reported ever using oral contraceptives: the odds ratio (OR) for ever vs never users was 1–1 (95% CI 0-8–1.3). The risk in current users was below unity when compared with never users (OR 0.3,95% CI 0.2–0.6), while ex-users had a risk of fibroids comparable with never users (OR 1. I, 95% CI 0.9–1.4). The risk of uterine fibroids decreased with duration of oral contraceptive use: compared with never users, the estimated OR was 0.8 (95% CI 0.5–1.2) in ever users for four to six years and 0.5 (95% CI 0.349) for seven years or more (trend = 4.6,   P = 0.03  ).
Conclusions Although the role of selection bias should be carefully evaluated, the present data suggest that uterine fibroids should not be considered a contra-indication for oral contraceptive use.     

Risk of myocardial infarction, angina and stroke in users of oral contraceptives: an updated analysis of a cohort study

Objectives To investigate risk of myocardial infarction, angina and stroke in users of contraceptive pills compared with users of other methods of contraception.
Design Prospective cohort study, with recruitment between 1968 and 1974 and annual follow up until the age of 45 years. After this age, only women who had never used oral contraception or those who had used it for eight or more years continued to be followed up annually until July 1994.
Setting Seventeen family planning clinics in England and Scotland.
Population 17,032 women aged between 25 and 39 years at entry to the study.
Main outcome measures Occurrence of angina, myocardial infarction or stroke that was associated with either hospital admission or outpatient referral to hospital or death.
Results Increased risk of myocardial infarction in oral contraceptive users was observed only in women who were heavy smokers at entry to the study. In this subgroup the relative risk of a myocardial infarction was 4.2 (95% CI 1.4–16.6) in ever users of oral contraception compared with non-users, 4–9 (1.2–23.6) in current users, and 4–0 (1.3–16.2) in ex-users. In all current users the relative risk of angina was 0.5 (0.1–1.4), and the relative risk of ischaemic stroke was 2.9 (1.3–6.7). The increased risk of ischaemic stroke did not persist in ex-users.
Conclusions Use of oral contraception is associated with increased risk of ischaemic stroke and increased risk of myocardial infarction (only in heavy smokers), but no increased risk of angina. These increased risks need to be considered within the context of the very low absolute risks of cardiovascular disease in this population. 5880 women need to take oral contraception for one year to cause one extra stroke, and 1060 women who are heavy smokers need to take it for one year to cause one extra myocardial infarction.     

Premature ovarian failure: frequency and risk factors among women attending a network of menopause clinics in Italy

Objective To determine the frequency and causes of preterm ovarian failure (menopause before 40 years of age) and early menopause (menopause between 40 and 45 years).
Design Cross sectional study.
Setting Menopause clinics in Italy.
Population Women attending menopause clinics in Italy.
Methods Between 1997 and 1999 we conducted a large cross sectional study on the characteristics of women around menopause attending a network of first-level outpatient menopause clinics in Italy for general counselling about menopause or treatment of menopausal symptoms. Eligible for the study were all women aged 45–75 years consecutively observed for the first time at the participating centres on randomly selected days during the study period.
Main outcome measure Factors associated with preterm ovarian failure.
Results Out of 15,253 women aged 55 years or more with spontaneous menopause who entered the study, 269 (1.8%) reported preterm ovarian failure, and 1085 (7.1%) reported spontaneous menopause at age 40–45 years. The risk of preterm ovarian failure and of early menopause was higher in women reporting lifelong irregular menstrual cycles: in comparison with women reporting menopause at age ≥45 years, the OR (irregular vs regular mestrual cycles) of preterm ovarian failure was 1.3 (95% CI 1.0–1.7) and of early menopause of 1.2 (95% CI 1.0–1.5). Parous women reported less frequently preterm ovarian failure (  χ²  trend   P < 0.05  ) and early menopause (OR 0.8, 95% CI 0.7–1.0). No significant association emerged between risk of preterm ovarian failure or menopause at age 40 to <45 and education, age at menarche, oral contraceptive use and smoking habits.
Conclusion Nulliparity and lifelong irregular menstrual cycles are associated with an increased risk of preterm ovarian failure.     

A randomised study comparing a low dose of mifepristone and the Yuzpe regimen for emergency contraception

Objective To compare 100 mg mifepristone with the standard Yuzpe regimen for emergency contraception.
Design Randomised controlled trial.
Setting Family Planning Clinic, Aberdeen.
Sample One thousand women seeking emergency contraception within 72 hours after an episode of unprotected sexual intercourse.
Methods Women were randomised to receive either 100 mg (half tablet) of mifepristone as a single dose or the Yuzpe regimen (two tablets each with 50 μg ethinyloestradiol and 0.25 mg levonorgestrel, to be repeated 12 hours later).
Outcome measures Crude pregnancy rates, proportion of pregnancies prevented, side effects and patient acceptability.
Results The crude pregnancy rates (95% CI) for the Yuzpe regimen and mifepristone were 3.6% (2.3–5.7) and 0.6% (0.2–1.8), respectively, with a significant difference between the two groups (RR 6.04; 95% CI 1.75–20.75). Mifepristone prevented 92% of pregnancies and the Yuzpe regimen preventing 56%. An increasing coitus to treatment interval was associated with contraceptive failure in the Yuzpe group (   P = 0.03  ) with no association seen with mifepristone. Following administration of mifepristone 24.5% and 13.1% given the Yuzpe regimen had a delayed period (RR 2.14; 95% CI 1.46–3.15). Overall, mifepristone was better tolerated than the Yuzpe regimen with significantly fewer side effects. More women were satisfied (   P < 0.0001  ) with mifepristone as an emergency contraceptive and would recommend it to a friend (   P = 0.02  ).
Conclusion Mifepristone administered in a 100 mg dose is a highly effective post-coital contraceptive with high patient acceptability and fewer side effects compared with the standard Yuzpe regimen. Delay in the onset of menstruation did not decrease patient acceptability.     

Association between antidepressant drug use during pregnancy and child healthcare utilisation

Objective  To evaluate healthcare utilisation by children who were exposed to antidepressant drug use during pregnancy and those whose mothers stopped using antidepressants before pregnancy compared with a control group.
Design  Cohort study.
Setting  Health insurance records in the Netherlands.
Population  A total of 38 602 children born between 2000 and 2005.
Methods  Survey of child healthcare utilisation in relation to gestational antidepressant use.
Main outcome measure  Healthcare utilisation rates during the first year of life, with special emphasis to medical care related to cardiac disease.
Results  Children of mothers who used antidepressants during pregnancy showed increased healthcare use during the first year of life, independent of the mother's healthcare use. The relative risk of more than two visits to general practitioners was 1.5 (95% confidence interval, CI: 1.3–1.8) in the continuous antidepressant users group and 1.3 (95% CI: 1.2–1.5) in the group of children whose mothers stopped taking medication. In both study groups there was a trend towards more drug use for infections and inflammation compared with the control group. Children continuously exposed to antidepressants had an increased risk of cardiac interventions such as cardiovascular surgery or heart catheterisation, relative risk of 5.6 (95% CI: 1.8–17.4). The risk of physiotherapy was twice as high in the antidepressant group compared with the control group (relative risk 2.0; 95% CI: 1.5–2.6).
Conclusion  Antidepressant use during pregnancy is associated with increased child healthcare utilisation and increased risk of major cardiac interventions in early childhood.     

Effect of postpartum pelvic floor muscle training in prevention and treatment of urinary incontinence: a one-year follow up

Objective To evaluate the long term effect of a postpartum pelvic floor muscle training course in prevention and treatment of urinary incontinence.
Design A prospective matched controlled trial.
Sample and methods All women who had participated in a matched controlled study evaluating the effect of an eight-week pelvic floor muscle training program in prevention and treatment of urinary incontinence in the immediate postpartum period were contacted by telephone one year after delivery. They were invited to participate in a follow up study. The study group consisted of 81 matched pairs (   n = 162  ), with a mean age (range) 28 years (19–40), and mean number (range) of deliveries 1.8 (1–5). Seventy-six pairs had normal vaginal deliveries and five elective caesarean sections. Registration of continence status was by structured interview and a standardised pad test. Clinical assessment of pelvic floor muscle function and strength were by vaginal palpation and vaginal squeeze pressure.
Main outcome measure Stress urinary incontinence.
Results At the one year follow up, significantly more women in the former control group than in the training group reported stress urinary incontinence and/or showed urinary leakage at the pad test (   P < 0.01  ). A significantly greater (   P < 0.01  ) muscle strength increase in the period between 16th week and one year postpartum was demonstrated in the former training group (mean 4.4 cm H₂ O, 95% CI 3.2–5.6) than in the control group (mean 1.7 cm H₂ O, 95% CI 0.8–2.7).
Conclusion This one year follow up study demonstrates that a specially designed postpartum pelvic floor muscle training course was effective in the prevention and treatment of stress urinary incontinence. The benefits from pelvic floor muscle training are still present one year after delivery.     

Survival and recurrent disease after postoperative radiotherapy for early endometrial cancer: systematic review and meta-analysis

Objective  To clarify the effect of postoperative (adjuvant) external-beam pelvic radiotherapy (EBRT) for different grades of early endometrial cancer.
Search strategy  Meta-analysis of data from randomised trials stratified by histological risk factors supported by cohort studies.
Selection criteria  Cochrane methodology.
Data  Seven randomised trials were identified. Five were eligible for meta-analysis. Homogeneity was confirmed ( I ² < 25%).
Main outcome measures  Survival, site of recurrence and added complications.
Main results  EBRT after hysterectomy for low-risk disease increases the odds of death (OR for overall survival 0.71; 95% CI 0.52–0.96). EBRT does not appear to alter survival for intermediate-risk cancers (stage ICG1/2 and IBG3) (OR 0.97; 95% CI 0.69–1.35). In contrast, EBRT offers a significant disease-free survival advantage for high-risk cancer (OR 1.76; 95% CI 1.07–2.89). The survival advantage benefits one in ten women. The definition of high risk is variable across studies but focuses on ICG3 (deeply invasive, poorly differentiated) tumours. Pelvic EBRT reduces the risk of pelvic recurrent disease in all types of invasive endometrial cancer (OR 0.27; 95% CI 0.16–0.44), but local recurrence may respond to salvage treatment. The risk of distant metastasis appears to be increased significantly by prophylactic EBRT (OR 1.58; 95% CI 1.07–2.35), but this might be because pelvic relapse in untreated women alters reporting of metastatic disease.
Authors' conclusions  Adjuvant EBRT should not be used for low- (IA, IBG1) or intermediate-risk (IBG2) cancer, but it is associated with a 10% survival advantage for high-risk (stage ICG3) endometrial cancer. This challenges the role of a staging lymphadenectomy.     

Levator trauma is associated with pelvic organ prolapse

Objective  To estimate the risk of prolapse associated with levator avulsion injury among a urogynaecological clinic population.
Design  Retrospective observational study.
Setting  Tertiary urogynaecological unit.
Sample  A total of 934 women seen for interview, examination using the pelvic organ prolapse quantification (POP-Q) staging system and imaging of the levator ani muscle by four-dimensional translabial ultrasound.
Methods  Retrospective review of charts and stored imaging data.
Main outcome measures  Pelvic organ prolapse stage II and higher and presence of defects of the levator ani muscle.
Results  After exclusion of 137 women with a history of anti-incontinence or prolapse surgery, and a further exclusion of 16 women in whom either examination or imaging was impossible, we compared prolapse and imaging data in 781 women. Mean age was 53 years (range 15–89 years), and median parity was 2 (range 0–12). Women reported stress incontinence (76%), urge incontinence (69%), frequency (47%), nocturia (49%) and symptoms of prolapse (38%). Significant prolapse (stage II or higher) was diagnosed in 415 (53%) women, and 181 (23%) women were found to have levator avulsion defects. Prolapse was seen in 150/181 (83%) women with avulsion and in 265/600 (44%) women without avulsion, giving a relative risk (RR) of 1.9 (95% CI 1.7–2.1). The association was strongest for cystocele (RR 2.3, 95% CI 2.0–2.7) and uterine prolapse (RR 4.0, 95% CI 2.5–6.5).
Conclusions  Women with levator avulsion defects were about twice as likely to show pelvic organ prolapse of stage II or higher than those without. This effect is mainly due to an increased risk of cystocele and uterine prolapse.     

Induced abortion in the first trimester of pregnancy and risk of miscarriage

Objective To analyse the relation between induced abortion and risk of subsequent miscarriage.
Design Case-control study conducted between February 1990 and May 1995.
Participants Case group included 782 women (median age 32 years, range 1446) admitted for spontaneous abortion (within the 12th week of gestation) to a network of obstetric departments in the greater Milan area. The control group was recruited among women who gave birth at term (> 37 weeks of gestation) to healthy infants on randomly selected days at the hospitals where cases had been identified. A total of 1543 controls (median age 30 years, range 14–45) were interviewed.
Results A total of 102 cases (13%) and 181 controls (12%) reported one or more induced abortions. No clear relation emerged between miscarriage and induced abortions. In comparison with women reporting no induced abortion the odds ratio (OR) for miscarriage were 1.1 (95% CI 0.8–1.4) in women reporting one induced abortion and 0.9 (95% CI 0.4–1.8) in women reporting two or more. Likewise, there was no association between time since last and age at first induced abortion and risk of miscarriage.
Conclusions This study did not find any strong association between induced and spontaneous abortion.     

Hormonal contraception and risk of sexually transmitted disease acquisition: results from a prospective study

OBJECTIVES: To examine the relationship between use of oral contraceptive pills or depot medroxyprogesterone acetate and sexually transmitted disease acquisition. STUDY DESIGN: Prospective cohort included 948 Kenyan prostitutes. Multivariate Andersen-Gill proportional hazards models were constructed, adjusting for sexual behavioral and demographic variables. RESULTS: When compared with women who were using no contraception, users of oral contraceptive pills were at increased risk for acquisition of chlamydia (hazard ratio, 1.8; 95% confidence interval, 1.1-2.9) and vaginal candidiasis (hazard ratio, 1.5; 95% confidence interval, 1.2-1.9) and at decreased risk for bacterial vaginosis (hazard ratio, 0.8; 95% confidence interval, 0.7-1.0). Women using depot medroxyprogesterone acetate had significantly increased risk of chlamydia infection (hazard ratio, 1.6; 95% confidence interval, 1.1-2.4) and significantly decreased risk of bacterial vaginosis (hazard ratio, 0.7; 95% confidence interval, 0.5-0.8), trichomoniasis (hazard ratio, 0.6; 95% confidence interval, 0.4-1.0), and pelvic inflammatory disease (hazard ratio, 0.4; 95% confidence interval, 0.2-0.7). Consistent condom use was associated with significantly decreased risk of gonorrhea, chlamydia, genital ulcer disease, bacterial vaginosis, and pelvic inflammatory disease. CONCLUSIONS: The use of oral or injectable hormonal contraception altered susceptibility to sexually transmitted diseases, which may in turn influence transmission of human immunodeficiency virus type 1. Consistent condom use was protective with regards to sexually transmitted disease and should be encouraged for the prevention of sexually transmitted disease and human immunodeficiency virus type 1 among women who use hormonal contraception.     

Risk factors for anal sphincter tears: the importance of maternal position at birth

Objective  To assess the role of birth position in the occurrence of anal sphincter tears (AST).
Design  Observational cohort study.
Setting  South Hospital in Stockholm, a teaching hospital with around 5700 births per year.
Population  Among all 19 151 women who gave birth at the South Hospital during the study period 2002–05, 12 782 women met the inclusion criteria of noninstrumental, vaginal deliveries.
Methods  Data on birth position and other obstetric factors were analysed in relation to occurrence of AST.
Main outcome measure  Third- and fourth-degree AST.
Results  AST occurred in 449 women (3.5%). The trauma was more frequent in primiparous (5.8%) than in multiparous women (1.7%). The highest proportion of AST was found among women who gave birth in lithotomy position (6.9%), followed by squatting position (6.4%). Logistic regression analyses showed that lithotomy (adjusted OR 2.02, 95% CI 1.58–2.59) and squatting positions (adjusted OR 2.05, 95% CI 1.09–3.82) were associated with a significantly increased risk for AST. Other major risk factors for anal sphincter trauma were primiparity (adjusted OR 3.29, 95% CI 2.55–4.25), prolonged second stage of labour >1 hour (adjusted OR 1.52, 95% CI 1.11–2.10), infant birthweight more than 4 kg (adjusted OR 2.12, 95% CI 1.64–2.72) and large infant head circumference (adjusted OR 1.57, 95% CI 1.23–1.99).
Conclusion  Lithotomy and squatting position at birth were associated with an increased risk for AST also after control for other risk factors.     

Does leisure time physical activity in early pregnancy protect against pre-eclampsia? Prospective cohort in Danish women

Objective  To examine the association between physical activity in early pregnancy and risk of pre-eclampsia.
Design  Prospective cohort.
Setting  Denmark.
Population  A total of 85 139 pregnant Danish women, recruited between 1996 and 2002.
Methods  The authors assessed leisure time physical activity in first trimester by a telephone interview and categorised women a priori into seven groups: 0 (reference), 1–44, 45–74, 75–149, 150–269, 270–419 and 420+ minutes/week. Pre-eclampsia diagnoses were extracted from the Danish National Patient Registry. A number of potential confounders were adjusted for by logistic regression.
Main outcome measures  Pre-eclampsia and severe pre-eclampsia.
Results  The two highest physical activity levels were associated with increased risk of severe pre-eclampsia compared with the nonexercising group, with adjusted odds ratios of 1.65 (95% CI: 1.11–2.43) and 1.78 (95% CI: 1.07–2.95), whereas more moderate levels of physical activity (1–270 minutes/week) had no statistically significant association with risk of pre-eclampsia (total n = 85 139).
Conclusions  We were unable to document a protective effect of leisure time physical activity against pre-eclampsia. Our data even suggest that leisure time physical activity exceeding 270 minutes/week in first trimester may increase risk of severe pre-eclampsia.     

Fetal macrosomia and pregnancy outcomes

Background:  Pregnancies with a macrosomic fetus comprise a subgroup of high-risk pregnancies. There is uncertainty in the clinical management and outcomes of such pregnancies.
Aim:  We sought to examine clinical management and maternal and fetal outcomes in pregnancies with macrosomic infants at Royal Brisbane and Women's Hospital (RBWH).
Methods:  Data from 276 macrosomic births (weighing ≥ 4500 g) and 294 controls (weighing 3250–3750 g) delivered during 2002–2004 at RBWH were collected from the hospital database. Univariate and logistic regression analyses were performed for maternal risk factors and maternal and neonatal outcomes that were associated with fetal macrosomia.
Results:  Macrosomia was more than two times likely in women with body mass index (BMI) of  > 30 kg/m² (odds ratio (OR) 2.41, 95% confidence interval (CI) 1.26–4.61) and in male infant sex (OR 2.05, 95% CI 1.35–3.12), and four times more likely in gestation of > 40 weeks (OR 3.93, 95% CI 1.99–7.74). Maternal smoking reduced the risk of fetal macrosomia (OR 0.27, 95% CI 0.14–0.51).
Macrosomia was associated with nearly two times higher risk of emergency caesarean section (OR 1.75, 95% CI 1.02–2.97) and maternal hospital stay of > 3 days (OR 1.66, 95% CI 1.11–2.50), and four times higher risk of shoulder dystocia (OR 4.08, 95% CI 1.62–10.29). Macrosomic infants were twice as likely to have resuscitation (OR 2.21, 95% CI 1.46–3.34) and intensive care nursery admission (OR 1.89, 95% CI 1.03–3.46).
Conclusion:  Macrosomia was associated with an increased risk of adverse maternal and neonatal health outcomes. Optimal management strategies of macrosomic pregnancies need evaluation.     

Grandmultiparae in a modern setting

Objective To compare the incidence of antenatal and intrapartum complications and neonatal outcomes among women who had previously delivered five or more times (grandmultiparous) with that of age-matched control women who had previously delivered two or three times (multiparous).
Design A matched cohort study.
Setting An inner city university maternity hospital in the United Kingdom.
Sample Three hundred and ninety-seven grandmultiparous women were compared with three hundred and ninety-seven age-matched multiparous women.
Methods Data on the subjects were obtained from a computerised maternity information system (SMMIS). Characteristics and complications occurring in the two groups were compared. Data validation was performed with a 10% randomised sample of the casenotes in both groups. Nineteen relevant data fields were abstracted and compared with the matched SMMIS record.
Results The overall incidence of intrapartum complications for grandmultiparous women was 16% compared with 18% in the control multiparous women (odds ratio 0.9, 95% CI 0.6–1.3). Grand multiparity was associated with a significantly higher body mass index at booking (   P <0.01  ) and the last antenatal clinic (   P < 0.05  ), an increased incidence of antenatal anaemia (22% vs 16%, odds ratio 1.8, 95% CI 1.2–2.8) and a decreased incidence of elective caesarean section (6% vs 11%, odds ratio 0.5, 95% CI 0.3–0.9). Agreement was greater than 95% in all the data fields reviewed except three. In the 14 categorical variables reviewed the Cohen's kappa results were in excess of 0.6.
Conclusion This study suggests that in a developed country with satisfactory health care conditions, grandmultiparity should not be considered dangerous, and risk assessment should be based on past and present history and not simply on the basis of parity.     

Post-operative endometriosis recurrence: a plea for prevention based on pathogenetic,epidemiological and clinical evidence

Prevention of the recurrence of post-operative endometriosis is crucial for future fertility. The incidence of disease relapse can be influenced by major demographic changes and by the use of long-term adjuvant medical treatment. Decrease in age at menarche, number of pregnancies and duration of breastfeeding and increase in age at first birth all lead to an increase in the overall number of ovulations and menstruations a woman has within a reproductive lifespan. These changes impact during the decade at highest risk for endometriosis, i.e. between 25 and 35 years of age, and may substantially expand the hiatus between first-line surgical treatment and conception attempt. Several lines of evidence suggest that ovulation inhibition reduces the risk of endometriosis recurrence. After pooling the results of a cohort and a randomized controlled trial on long-term post-operative oral contraceptive use, a recurrent endometrioma developed in 26/250 regular users (10%; 95% CI 7–15%) compared with 46/115 never users (40%; 95% CI 31–50%), with a common OR of 0.16 (95% CI 0.04–0.65). After first-line surgery for endometriosis, women should be invited to seek conception as soon as possible. Alternatively, oral contraceptive use until pregnancy is desired should be considered.     

The incidence of preterm deliveries decreases in Finland

Objective  We examined the trends and risk factors of preterm delivery.
Design  Register-based retrospective cohort study from Finland.
Setting  National Medical Birth Register data during 1987–2005.
Population  The study population consisted of 1 137 515 deliveries, of which 59 025 were preterm (5.2%).
Methods  We calculated the population attributable risks for using the risk factor prevalence rates in the population. We further calculated odds ratios with 95% CI by multivariate logistic regression to adjust for confounders.
Main outcome measures  Preterm delivery rate subclassified into moderately preterm (32–36 weeks), very preterm (28–31 weeks) and extremely preterm (less than 28 weeks).
Results  Preterm delivery rates increased from 5.1% in the late 1980s to 5.4% in the late 1990s but then decreased to 5.2% for 2001–05. The proportion of extremely preterm deliveries decreased substantially by 12% ( P < 0.01). The greatest risk factors were multiplicity (OR 13.72, 95% CI 13.26–14.19), followed by elective delivery (OR 1.86, 95% CI 1.82–1.89), primiparity (OR 1.47, 95% CI 1.45–1.50), in vitro fertilisation treatment (OR 1.39, 95% CI 1.31–1.47), maternal smoking (OR 1.31, 95% CI 1.29–1.34) and advanced maternal age (OR 1.02, 95% CI 1.02–1.03 for each additional year of age). Prematurity rates decreased by 1.8% after adjusting for risk variables.
Conclusions  The rate of preterm delivery has not increased from 1987 to 2005 in Finland, while the risk for extremely preterm delivery has decreased. This finding is in contrast with recent trends in other countries.     

Is the intrauterine device appropriate contraception for HIV-1-infected women?

Objective To assess whether the risk of complications is higher in HIV-1-infected women compared with non-infected women in the two years following insertion of the intrauterine contraceptive device.
Design Prospective cohort study.
Population Six hundred and forty-nine women (156 HIV-1-infected, 493 non-infected) in Nairobi, Kenya who requested an intrauterine contraceptive device and met local eligibility criteria.
Methods We gathered information on complications related to the use of the intrauterine contraceptive device, including pelvic inflammatory disease, removals due to infection, pain or bleeding, expulsions, and pregnancies at one, four, and 24 months after insertion by study physicians masked to participants' HIV-1 status. Cox regression was used to estimate hazard ratios.
Results Complications were identified in 94 of 636 women returning for follow up (14.7% of HIV-1-infected, 14.8% of non-infected). The incidence of pelvic inflammatory disease was rare in both infected (2.0%) and non-infected (0.4%) groups. Multivariate analyses suggested no association between HIV-1 infection and increased risk of overall complications (hazard ratio=1.0; 95% CI 0.6-1.6). Infection-related complications (e.g. any pelvic tenderness, removal for infection or pain) were also similar between groups (10.7% of HIV-1-infected, 8.8% of non-infected; P =0.50), although there was a non-significant increase in infection-related complications among HIV-1-infected women with use of the intrauterine contraceptive device longer than five months (hazard ratio=1.8; 95% CI 0.8-4.4). Neither overall nor infection-related complications differed by CD4 (immune) status.
Conclusions HIV-1-infected women often have a critical need for safe and effective contraception. The intrauterine contraceptive device may be an appropriate contraceptive method for HIV-1-infected women with ongoing access to medical services.     

Risk factors for ovarian cancer in central Italy

OBJECTIVE: We conducted a case-control study to analyze risk factors for ovarian cancer. METHODS: Cases included 440 women (age range 13-80 years, median 54) with a histologically confirmed diagnosis of epithelial ovarian cancer who were admitted to the Gynecological Oncological Department of Gynecologic Oncology at the Catholic University Hospital in Rome, Italy. Controls were women admitted to the same hospital where cases were identified for acute nongynecological, nonhormonal, and nonneoplastic conditions. A total of 868 control women (age range 19-80 years, median 55) were interviewed. RESULTS: In comparison with ever married women, the multivariate odds ratios (OR) of ovarian cancers was 2.0 (95% confidence interval, CI 1.3-3.2) for never married women. Cases and controls were similar as regards educational status and body mass index. No clear relation emerged between ovarian cancer and age at menarche, menopausal status, and age at menopause. In comparison with nulliparae, the estimated ORs were 0.8, 0.9, and 0.7, respectively, in women reporting one, two, or three births. Women reporting two or more induced abortions were at decreased risk of ovarian cancer (OR 0.5, 95% CI 0.3-1.0). In comparison with women reporting their first birth before 20 years of age, the multivariate ORs were 1.8, 2.0, and 2.8, respectively, for women reporting their first birth at age 20-24, 25-30, and >/=31 (chi(2) trend = 10.1). Breast-feeding for more than 1 year was associated with an OR of 0.5 (95% CI, 0.4-0.8). Forty-two (9.5%) cases and 164 (18.9%) controls reported ever oral contraceptive use: in comparison with never users, the multivariate OR was 0.4 (95% CI 0.3-0.6) for ever users, and the risk decreased with duration of use. The OR for ovarian cancer was 2.9 (95% CI, 1.5-5.8) for women with a family history of the disease. CONCLUSION: This study, conducted on a relatively low-risk population, confirms the role of oral contraceptive on ovarian cancer risk and the direct association with family history of ovarian cancer. It also indicates that a later age at first birth is directly, and induced abortion and breast-feeding are inversely, related to the risk of the disease.