Risk factors and the choice of long-acting reversible contraception following medical abortion: effect on subsequent induced abortion and unwanted pregnancy

Objective: To analyse the post-abortion effect of long-acting reversible contraception (LARC) plans and initiation on the risk of subsequent unwanted pregnancy and abortion.

Materials and methods: retrospective cohort study of 666 women who underwent medical abortion between January–May 2013 at Helsinki University Hospital, Finland. Altogether 159 (23.8%) women planning post-abortion use of levonorgestrel-releasing intrauterine system (LNG-IUS) participated in a randomized study and had an opportunity to receive the LNG-IUS free-of-charge from the hospital. The other 507 (76.2%) women planned and obtained their contraception according to clinical routine. Demographics, planned contraception, and LARC initiation at the time of the index abortion were collected. Data on subsequent abortions were retrieved from the Finnish Abortion Register and electronic patient files until the end of 2014.

Results: During the 21 months ([median], IQR 20–22) follow-up, 54(8.1%) women requested subsequent abortions. When adjusted for age, previous pregnancies, deliveries, induced abortions and gestational-age, planning LARC for post-abortion contraception failed to prevent subsequent abortion (33 abortions/360 women, 9.2%) compared to other contraceptive plans (21/306, 6.9%) (HR 1.22, 95% CI 0.68–2.17). However, verified LARC initiation decreased the abortion rate (4 abortions/177 women, 2.3%) compared to women with uncertain LARC initiation status (50/489, 10.2%) (HR 0.17, 95% CI 0.06–0.48). When adjusted for LARC initiation status, age?<25 years was a risk factor for subsequent abortion (27 abortions/283 women, 9.5%) compared to women?≥25 years (27/383, 7.0%, HR1.95, 95% CI 1.04–3.67).

Conclusions: Initiation of LARC as part of abortion service at the time of medical abortion is an important means to prevent subsequent abortion, especially among young women.     

Knowledge of emergency contraception among women aged 18 to 44 in California

OBJECTIVE: The State of California has taken several steps to make emergency contraceptives (ECs) available to women in the state. By using data from the 1999-2001 California Women's Health Survey, we estimated the knowledge of emergency contraception among adult women of reproductive age at risk of pregnancy (n=6209). STUDY DESIGN: This study is based on 3 years of data (1999-2001) from the California Women's Health Survey (CWHS), an annual population-based survey of more than 4000 randomly selected adult women (aged 18 years and older) in California. A total of 6198 women aged 18 to 44 responded to the 2 emergency contraception questions: "To the best of your knowledge, if a woman has unprotected sex is there anything she can do in the 3 days after intercourse that will prevent pregnancy?" and "What can she do?" RESULTS: We find that 38% of California women were able to correctly identify emergency contraception. Most importantly, the women who are most likely to need emergency contraception-those who are at risk of an unintended pregnancy but not using any method of contraception-have among the lowest levels of knowledge (only 29% identified a method of ECs). CONCLUSION: Results show that family planning providers may be reaching their clients, but broader outreach to the public has not yet achieved sufficiently high information levels among women in greatest need of the method.     

Medical eligibility,contraceptive choice,and intrauterine device acceptance among HIV-infected women receiving antiretroviral therapy in Lilongwe,Malawi

Objective

To determine medical eligibility for contraceptive use, contraceptive preference, and acceptance of a copper intrauterine device (IUD) among a cohort of HIV-infected women receiving antiretroviral therapy (ART).

Methods

All HIV-infected women who received ART and sought contraceptive services at the Lighthouse clinic, an integrated HIV/ART clinic in Lilongwe, Malawi, between August and December 2010 were invited to participate in a structured interview. Eligibility and preference for the following contraceptive methods were assessed: combined hormonal contraceptives, progestogen-only pills, copper IUD, injectable depot medroxyprogesterone acetate (DMPA), and contraceptive implants.

Results

The final sample included 281 women; five were pregnant. The remaining 276 women were eligible for at least three contraceptive methods, with 242 (87.7%) eligible for all five methods evaluated. After counseling, 163 (58.0%) selected DMPA and 98 (34.9%) selected an IUD as their preferred contraceptive method. Regardless of their method of choice, 222 (79.0%) women agreed to have an IUD placed on the same day.

Conclusion

Most methods of contraception are safe for use by HIV-infected women. Approximately 80% of the women were willing to receive an IUD. Efforts must be made to increase education about, and access to, long-acting reversible methods that may be acceptable and appropriate contraceptive options for HIV-infected women.     

Ruptured ectopic pregnancy: risk factors for a life-threatening condition

Introduction  Ectopic pregnancy is a significant cause of maternal morbidity and mortality. The widely used features to establish the diagnosis of ectopic pregnancy are not always sufficient to predict rupture. Problem  To determine the risk factors for rupture of an ectopic pregnancy to help physicians identify those women who are at greatest risk. Materials and methods  The study group comprises the cases of ectopic pregnancy who were treated in the gynecologic department of the General Hospital “George Gennimatas” in Athens, Greece, from January 1988 to December 2006. The following parameters were retrospectively examined: rupture status, past history of pelvic infection or ectopic pregnancy, use of IUCD, operations for infertility treatment/tubal surgery, parity and gestational age. The study group was divided into two subgroups: ruptured ectopic pregnancies and unruptured ectopic pregnancies. Where appropriate, Student’s t test, Mann–Whitney–Wilcoxon test for independent samples, Pearson’s chi-square and Fisher’s exact test were applied. Statistical analysis was performed with STATA 8.0 statistical software. Results  Two hundred and twenty-three cases of ectopic pregnancy were retrieved in the studied period. One hundred and forty-four (65%) of them were cases with ruptured ectopic pregnancies and 79 (35%) were cases with unruptured ectopic pregnancies. Fifty-five of the 144 patients (38.2%) with ruptured ectopic pregnancy and 18 of the 79 (22.8%) patients with unruptured ectopic pregnancy had a past history of ectopic pregnancy (P = 0.019, Pearson’s chi-square). Moreover, there was a statistically significant positive association between rupture and parity (1.19 ± 1.02 for ruptured cases vs. 0.85 ± 0.89 for unruptured cases; P = 0.015, Mann–Whitney–Wilcoxon test for independent samples). A positive association of borderline significance existed between rupture and gestational age (53.9 ± 4.7 vs. 52.9 ± 4.9 days; P = 0.093, Mann–Whitney–Wilcoxon test for independent samples). No statistically significant associations were found concerning past history of pelvic infection, use of IUCD and operations for infertility treatment–tubal surgery. Conclusions  Previous history of ectopic pregnancy and parity seem to be significant risk factors for rupture of an ectopic pregnancy.     

Factors affecting unmet need for contraception among currently married fecund young women in Bangladesh

Objectives: The aim of our study was to explore the factors associated with unmet need for contraception among currently married fecund women under age 25, in Bangladesh.

Methods: This study utilised a cross-sectional data (n?=?4982) extracted from the Bangladesh Demographic and Health Survey (BDHS) 2011. Multinomial logistic regression was used to identify the determinants of unmet need for contraception among currently married fecund young women.

Results: The unmet need for contraception was 17% and contraceptive prevalence was 54% in this young group. Total demand for contraception was 71% and the proportion of demand satisfied was 77%. The results suggest that region, place of residence, religion, husband’s desire for children, visits of FP workers, decision-making power on child health care, reading about FP in newspaper/magazine and number of births in three years preceding the survey were significant predictors of unmet need for contraception.

Conclusions: The BDHS of 2011 found that unmet need for contraception among currently married, fecund women under 25 years old is higher than the national level, and hence different or more intensive programme initiatives are required for them than for older women. The present study identifies important predictors of unmet need for contraception among fecund married Bangladeshi women under age 25.     

Risk factors for urinary incontinence among women aged 60 or over with hypertension in Taiwan

ObjectiveTo assess the associated risk factors and the prevalence of urinary incontinence (UI) among women with hypertension (H/T) aged 60 or over in Taiwan.Materials and MethodsA total of 2410 women aged 60 or over were selected by a multistage random sampling method and a total of 1519 women completed the face-to-face interviews. Only women who answered “yes” to the question “Do you have H/T?” were included in the H/T sample. The factors were assessed by frequency and Pearson's χ² test using a significance level of p < 0.05. Logistic regression was used to investigate the significance of dichotomous dependent variables.ResultsA total of 39.7% (602 women) interviewees had H/T, among which 39.9% (240 women) had UI symptoms. The prevalence of UI among women aged 60 or over with or without H/T was significantly different (p = 0.006). Risk factors were age [odds ratio (OR) = 1.043, 95% confidence interval (CI) 1.016–1.071, per year], diabetes mellitus (DM) (OR = 1.653, 95% CI 1.105–2.474), previous urinary diseases (OR = 3.462, 95% CI 2.260–5.301), and body mass index (BMI; OR = 1.060, 95% CI 1.012–1.110, per unit). There was no significant association between UI and drug allergy, smoking, hysterectomy, hormone therapy, or gynecological surgery.ConclusionUI can be a frequent and annoying problem for aged women. In women with H/T, UI is significantly related to risk factors such as age, DM, BMI, and urinary diseases. In addition, BMI is considered a key risk factor for H/T. Therefore, effective control of BMI would help in controlling H/T and UI in aged women.     

Risk factors for repeat abortion and implications for addressing unintended pregnancy in Vietnam

Objective

To determine predictors of repeat abortion in 3 provinces in Vietnam.

Methods

In a cross-sectional study between August and December 2011, women who underwent abortion were interviewed after the procedure in 62 public health facilities in Hanoi, Khanh Hoa, and Ho Chi Minh City (HCMC). Information on sociodemographic factors, contraceptive and reproductive history and intentions, and opinions and experience of abortion services was collected. The primary outcome was repeat (≥ 2) abortions.

Results

Overall, 1224 women were interviewed: 534 from Hanoi, 163 from Khanh Hoa, and 527 from HCMC. The mean age and parity of the respondents were 29 years and 1.8, respectively, and 79.6% were married. Approximately half of the respondents were not using contraception before pregnancy. The prevalence of repeat abortion was 31.7%. In multivariate models, significant predictors of repeat abortion included living in Hanoi, higher parity, age 35 years or older, and having 2 or more daughters (versus 1) or no sons (versus 1) after controlling for parity (all P < 0.05).

Conclusion

Repeat abortion remains high in Vietnam, fueled partly by inadequate contraceptive use. Son preference seems to be an important predictor of repeat abortion. Strengthening post-abortion contraceptive counseling and promoting long-acting contraceptive methods are essential to reduce repeat abortion.     

Effect of desogestrel 75 µg on headache frequency and intensity in women with migraine: a prospective controlled trial

Objective: In contrast with combined hormonal contraception, progestin-only contraception is not associated with an increase in venous thromboembolism or stroke. Women with migraine are at increased risk of ischaemic stroke. Several studies have reported a reduction in migraine frequency and intensity with desogestrel 75 µg, a progestin-only pill. At present the quality of data is limited by retrospective study designs, lack of control groups and small sample sizes. We present the first prospective nonrandomised controlled trial.

Methods: A total of 150 women with migraine visiting our clinic for contraceptive counselling were screened. The intervention group comprised women who opted for contraception with desogestrel (n?=?98); the control group comprised women who continued their usual contraceptive (n?=?36). Participants completed daily diaries for 90 days before the intervention and 180 days after the intervention.

Results: In the intervention group, we found improvements in migraine frequency (p?<?.001), migraine intensity (p?<?.001) and the number of triptans used (p?<?.001). These improvements were already significant after 90 days of desogestrel use (p?<?.001). Disability scores also decreased significantly. No improvement was seen in the nonintervention group.

Conclusion: These data demonstrate for the first time in a prospective controlled setting that daily use of the progestin desogestrel is associated with a decrease in migraine frequency, migraine intensity and pain medication use in women with migraine, with and without aura, who had previously been experiencing at least three days of migraine per month.

Trial registration: The study is registered in the University of Zürich database (www.research-projects.uzh.ch/unizh.htm).     

Effects of metformin and ethinyl estradiol-cyproterone acetate on clinical,endocrine and metabolic factors in women with polycystic ovary syndrome

Background. Polycystic ovary syndrome (PCOS) is a major endocrine abnormality that affects women of reproductive age. Oral contraceptive pills are usually the first choice of treatment for PCOS when fertility is not desired. Metformin, an insulin-sensitizing drug, has been shown to improve such metabolic abnormality.

Aim. To compare the effects of a contraceptive pill in combination with metformin on the clinical, endocrine and metabolic parameters in obese and non-obese patients with PCOS.

Methods. Sixty PCOS patients (25 obese, 35 non-obese) were enrolled in this prospective clinical study. PCOS was defined according to the Rotterdam criteria. Patients were randomized to oral treatment with Diane35® (35 μg ethinyl estradiol plus 2 mg cyproterone acetate), metformin or a combination of Diane35/metformin for 3 months. Body mass index (BMI), waist-to-hip ratio (WHR), Ferriman–Gallwey (FG) score, leuteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone, fasting insulin and glucose/insulin ratio were measured at baseline and at the end of treatment.

Results. Diane35 resulted in a higher reduction of FG score in both obese and non-obese PCOS patients compared with metformin. Menstrual regularity was restored in all PCOS patients treated with Diane35 compared with only 28% of those receiving metformin. Metformin significantly decreased BMI and WHR in obese patients (p < 0.05). Testosterone levels decreased in all three groups. LH levels and LH/FSH ratio decreased with Diane35 and Diane35/metformin in both obese and non-obese patients. Metformin significantly decreased fasting insulin concentrations (p < 0.05 and p < 0.01) and increased the insulin sensitivity (p < 0.05) in both obese and non-obese PCOS patients, while no significant changes were observed in the Diane35 group. In addition, insulin levels also decreased (p < 0.05) in the Diane35/metformin group.

Conclusions. Our data show that a combination of metformin and contraceptive pill may be more effective in suppressing the hyperandrogenemia of obese and non-obese PCOS patients than metformin alone and may reduce insulin levels more than contraceptive pill alone. Hence, combined treatment may become a more effective therapeutic option for PCOS.     

The impact of social factors on attendance at antenatal care services and the subsequent effect on mothers’ health, measured during the years of economic transition in Latvia

The goal of the study is to evaluate the risk factors having an impact on attendance at antenatal care services in Latvia during the years of economic transition as well as the impact of those factors on mothers and newborns’ health. Based on Latvian statistical data and published surveys, we analysed the possible impact of social and economic factors on attendance at antenatal care services. To illustrate the posed problems, we carried out a small pilot follow-up study, comparing social profiles, incidences of reproductive tract infections and HIV infection and pregnancy outcome on 200 consecutive unselected pregnant women who received antenatal care and 25 pregnant women who did not. Despite the fact that antenatal care is free of charge and the social security system facilitates the attendance of antenatal care visits, 4.6% of pregnant women in 1997 and 3.3% of pregnant women in 2002 did not attend antenatal care. Their perinatal outcome is significantly worse, as they are more likely to deliver preterm and growth-retarded babies and have a greater risk of perinatal mortality. Women delivering without previous antenatal care were characterised by poor socio-economic status and have limited access to health care and family planning services due to their low educational level, low income and high incidence of different addictions. More frequently, they were in the risk group having sexually transmitted and HIV infections. As a result, newborns had lower birth weight, were more likely to have intrauterine infection and intrauterine growth retardation. Low social class, high substance abuse, and a high rate of genital infections are associated with lack of antenatal care and compromised neonatal outcome. Improving the availability of primary health care and easy access to social and family planning services are priorities for the socially depressed during the reform period of the health care system in Latvia. Standard protocols for the management of women without previous antenatal care have to be developed.     

Risk for recurrence of preeclampsia and outcome of subsequent pregnancy in women with preeclampsia in their first pregnancy

Objective: To assess subsequent pregnancy outcome and to identify risk factors for recurrence of preeclampsia (PET) in women with PET in their first pregnancy. Methods: A retrospective cohort study of all nulliparous women diagnosed with PET during the years 1996–2008 (PET group, N = 600). Outcome of subsequent pregnancy was compared with a control group of nulliparous women without PET matched by maternal age in a 3:1 ratio (N = 1800). Results: Subsequent pregnancies in the PET group were characterized by a higher rate of preterm delivery at less than 37 and 34 weeks (15.2% vs. 5.7%, p < 0.001 and 3.8% vs. 0.8%, p < 0.001, respectively), placental abruption (1.7% vs. 0.2%, p = 0.004), IUGR (2.8% vs. 0.9%, p = 0.016), and PET (5.9% vs. 0.8%, p < 0.001). Risk factors for PET and adverse outcome in the subsequent pregnancy included: PET complicated by placental abruption in the index pregnancy (OR = 10.8, 95%-CI = 1.8–34.6), PET requiring delivery prior to 34 weeks in the index pregnancy (OR = 6.5, 95%-CI = 1.6–22.5), chronic hypertension (OR = 5.3, 95%-CI = 1.9–12.7), and maternal age > 35 (OR = 4.3, 95%-CI = 1.2–20.5). Conclusion: PET in the first pregnancy is independently associated with an increased risk for adverse pregnancy outcome and recurrence of PET in the subsequent pregnancy in a manner that is related to the severity of PET in the first pregnancy.