宫内节育器与疼痛

<正>宫内节育器(IUD)最早在1909年用于避孕,但其广泛研制始于20世纪60年代,它作为一种高效、安全、简便、经济、可逆且长效的避孕方法,已成为我国妇女避孕节育的主要措施之一,其中39.1%的妇女正在使用IUD。我国自1959年开始推广     

Intrauterine device and ectopic pregnancy

In Turku, Finland, 345 ectopic pregnancies were diagnosed in the period 1966 – 1975. Calculated from the number of deliveries, the incidence of ectopic pregnancy was 0.60 % in 1966 – 70, and 1.08 % in 1971 – 75. This difference is significant (p < 0.001). During the period studied, 59 cases of ectopic pregnancy presented with an intrauterine device $\text{in situ}$, thus accounting for 17 % of the total number seen. The use of intrauterine devices increased considerably after 1972. From that year, 29 % of all ectopic pregnancies occurred with an intrauterine device $\text{in situ.}$ Our findings accord well with other investigations, which emphasize the major role of intrauterine devices in raising the incidence of ectopic pregnancy.     

Intrauterine device and pelvic inflammatory disease

The IUD ML Cu375 was inserted, after bacteriological screening, into 620 women who were observed for 12 months.Bacterioscopy and, when needed, bacteriology of vaginal smears were performed 7 days, and 1, 3, 6 and 12 months after insertion. During the 12 months, pelvic inflammatory disease (PID) was diagnosed in 4 patients (0.6%) and sexually transmitted disease (STD) in 73 patients (11.8%).Careful selection of patients and bacteriological screening can effectively reduce the risk of bacterial contamination and subsequent development of PID.     

Intrauterine device insertion after medical abortion

Background

Studies comparing immediate intrauterine device (IUD) insertion after first-trimester surgical abortion with interval insertion show similar efficacy and expulsion rates. However, women randomized to interval insertion of an IUD are less likely to return for device placement. An ideal time to insert intrauterine contraception may be the day a woman presents for verification of a completed medical abortion. We examined immediate insertion of IUDs after completed first-trimester medical abortion.

Study Design

This is a prospective, observational clinical study to determine expulsion rates of intrauterine contraception placed immediately after confirmed, completed first-trimester medical abortion.

Results

Of 118 subjects, 78 women had levonorgestrel IUDs placed, whereas 41 women received copper IUDs. Of 97 subjects who completed the study, there were 4 clinical expulsions (4.1%) during 3 months of follow-up. There were no diagnosed pelvic infections, pregnancies, or uterine perforations. The continuation rate at 3 months was 80%.

Conclusion

Intrauterine devices inserted at the time of completed, confirmed first-trimester medical abortion have low rates of expulsion.     

Education through telemedicine networks: setting quality standards

Quality standards for educational programming have received limited attention in telemedicine. We selected five sets of standards from the distance education literature established by: (1) the American Council on Education; (2) the American Distance Education Consortium; (3) the Council of Regional Accrediting Commissions; (4) the Distance Education and Training Council; (5) the Innovations in Distance Education Project. The standards were reviewed to determine the purposes they were intended to serve and the process by which they were established. The content of the five sets of standards were summarized around the 'four commonplaces' of education: learner, teacher, curriculum and context. Four major findings emerged. First, none of the sets of standards addresses all of the issues that are potentially relevant to telemedicine education; all emphasize certain topics while neglecting others. Second, there are some important aspects of telemedicine that are not addressed at all, such as patient confidentiality. Third, the standards generally provide a framework for defining high quality in distance education, leaving to those at the local level the task of deciding how a standard applies in their setting. Finally, the standards reviewed have many elements that could potentially apply to telemedicine education. Setting quality standards for education through telemedicine requires a systematic approach and a means for continuous improvement of those standards.     

Intrauterine device insertion during the postpartum period: a systematic review

Background

Insertion of an intrauterine device (IUD) at different times or by different routes during the postpartum period may increase the risk of complications.

Methods

We searched Medline, Lilacs and Cochrane Collaboration databases for articles in any language, between database inception until December 2008, which compared outcomes of postpartum IUD insertion time intervals. Search terms included postpartum, puerperium, postcesarean delivery, cesarean section, IUD(s), IUCD(s), intrauterine device(s) and insertion.

Results

From 297 articles, we identified 15 for inclusion in this review: all studies examined the outcomes from copper IUD insertions within the postpartum time period compared to other time intervals or compared routes (vaginal or via hysterotomy) of postpartum insertion. No studies of levonorgestrel IUDs were identified.Immediate IUD insertion (within 10 min of placental delivery) was safe when compared with later postpartum time periods and interval insertion. Immediate postpartum IUD insertion demonstrated lower expulsion rates when compared with delayed postpartum insertion but with higher rates than interval insertion. Immediate insertion following cesarean delivery demonstrated lower expulsion rates than immediate insertion following vaginal delivery.

Conclusion

Poor to fair quality evidence from 15 articles demonstrated no increase in risk of complications among women who had an IUD inserted during the postpartum period; however, some increase in expulsion rates occurred with delayed postpartum insertion when compared to immediate insertion and with immediate insertion when compared to interval insertion. Postplacental placements during cesarean delivery are associated with lower expulsion rates than postplacental vaginal insertions, without increasing rates of postoperative complications.     

Intrauterine device retention: a study of selected social-psychological aspects.

A retrospective study of the association between selected sociopsychological variables and the early discontinuation of intrauterine device use was carried out among patients of the Central Clinic of Family Health, Inc., New Orleans, Louisiana. In toto, 270 women cooperated in a standardized interview which was administered by trained auxiliaries of the clinic's staff; Investigation of sociodemographic characteristics shows a greater proportion of the terminators to be younger, more mobile, and to have experienced more changes in marital partners. Continuers are at greater health risk in pregnancy as rated by the clinic at time of admission, but do not verbalize this as a concern. Responses relating to sexuality image and contraceptive attitudes indicate that a greater proportion of the terminators dislike an internal IUD self string check, hold a more pro-pregnancy attitude, do not feel dependent on the availability of contraceptives, and currently utilize the less effective contraceptive methods. Few significant differences are reported in the side effects experienced after IUD insertion by the terminators or continuers. However, the groups hold decidely different perceptions of the meaning of such complaints. A greater proportion of the terminators perceive themselves as being sick, take to bed during the menses, find that complaints disrupt their normal household activities, and are fearful of the meaning to their health of the difficulties experienced. The majority of both groups are functioning in a segregated marital role pattern. Terminators portray a tendency to be interacting with more "traditional" husbands who visualize the proper role for their wives as mothers whose duty it is to stay home. Continuers, to a greater degree, are more dominant individuals, make more decisions in the running of the home, and feel that contraception is their responsibility alone. Program implications take direction from the findings that the terminator is a more "costly" patient in terms of physician time and is at a decidely greater risk of final closure to all clinic contacts.     

Intrauterine device and maternal copper metabolism during lactation

The effects of intrauterine device (IUD) on maternal copper (Cu) metabolism during breastfeeding was studied in 95 volunteer mothers who chose to use non-hormonal contraceptive methods. They were divided into two groups that were inserted with the IUD-Cu 380A (n = 33), IUD-Cu 200B (n = 29), and a third group that did not use any IUDs served as control (n = 33). Endometrial biopsies, blood, and milk samples were collected before (at 10 weeks postpartum) and 6 weeks after insertion of device for the determination of metabolites associated with copper metabolism, namely, serum ceruloplasmin, and copper concentrations in breast milk and endometrium. Endometrial copper concentration increased in women using IUDs, but was statistically significant (p = 0.001) only in the IUD-Cu 380A group. The increase in endometrial copper concentration did not affect serum ceruloplasmin or milk copper concentrations.     

Intrauterine device use among women with uterine fibroids: a systematic review

Background

There are concerns that intrauterine device (IUD) use by women with uterine fibroids might increase their uterine bleeding or risk for device expulsion. The objective of this systematic review was to evaluate evidence concerning the safety and effectiveness of IUD use among women with uterine fibroids. Key questions included whether IUD use is associated with increased risk for uterine bleeding among women with uterine fibroids and whether the presence of uterine fibroids is associated with an increased risk for device expulsion among IUD users.

Study Design

We searched the PubMed database for peer-reviewed articles relevant to IUD (copper or levonorgestrel-releasing) use and uterine fibroids published in any language from database inception through June 2009. We used standard abstract forms and a grading system to summarize and assess the quality of the evidence.

Results

From 202 articles found in the database search, we identified 11 studies that met our inclusion criteria, all of which examined outcomes among users of the levonorgestrel-releasing IUD (LNG-IUD). Evidence from 10 of 11 noncomparative studies (Level II-3, fair) suggests that LNG-IUD use among women with fibroids does not increase menstrual bleeding, and results from all 11 showed that menstrual blood loss decreased among women who continued to use the LNG-IUD through the end of the study period. Overall, serum levels of hemoglobin, hematocrit and ferritin increased among LNG-IUD users in studies that assessed these outcomes. Several studies reported some occurrences of irregular bleeding. Findings from two cohort studies (Level II-2, fair to poor) showed rates of LNG-IUD expulsion to be higher among women with uterine fibroids (11% in each) than among women without uterine fibroids (0% and 3%); however, in one study the difference was not statistically significant, and in the other significance testing was not conducted. Six prospective noncomparative studies reported expulsion rates of 0-20% among women with uterine fibroids.

Conclusions

Most women with uterine fibroids are likely to have less menstrual blood loss and higher serum levels of hemoglobin, hematocrit and ferritin after insertion of an LNG-IUD, despite some occurrences of irregular bleeding. LNG-IUD users with uterine fibroids may have higher rates of expulsion than those without fibroids.     

Intrauterine device use among women with ovarian cancer: a systematic review

Background

Fertility-sparing treatment may be an option for women with early stage ovarian cancer and certain tumor types. This systematic review evaluated the evidence on the safety of intrauterine device (IUD) use by women with ovarian cancer.

Study Design

We searched the PubMed database for peer-reviewed articles relevant to IUD (copper or levonorgestrel-releasing) use and ovarian cancer published in any language from database inception through August 2009. We sought studies that examined outcomes among women using an IUD at or after ovarian cancer diagnosis.

Results

Of the 250 articles identified by our search strategy, none provided evidence (direct or indirect) regarding the safety of IUD use among women with ovarian cancer.

Conclusions

No evidence on the safety of IUD use among women with ovarian cancer was identified. While there are some theoretical concerns that IUD use might affect monitoring of disease progression of sex cord-stromal tumors, or increase risk of pelvic infection or vaginal bleeding among women undergoing chemotherapy, we did not find any data to suggest that IUD use would lead to worsening of primary ovarian cancer.     

Standard setting for progress tests: combining external and internal standards

Objectives  There has been little work on standard setting for progress tests and it is common practice to use normative standards. This study aimed to develop a new approach to standard setting for progress tests administered at the point when students approach graduation.
Methods  In this study we obtained performance data from newly qualified doctors and used this information to set the standard for the last progress test in the final year of undergraduate medical education. This external reference was validated against projections of student performance data based upon normative grading, and other published results. A simple linear growth model was used to set pass scores for progress tests earlier in the final year and this was also validated by published data.
Results  There was good agreement between standards set using the data from newly qualified doctors, the standard expected from extrapolation of the student progression data, and published performance data from another medical school.
Conclusions  We have demonstrated that a combination of data from independent sources can be used to triangulate standard-setting decisions for progress tests. Performance data from successive cohorts of medical students could provide a fruitful source of information for standard setting for progress tests.     

Near-patient tests in primary care: setting the standards for evaluation

Near-patient tests (NPT) are an area of rapid technological advance that may enhance the quality of care given by primary care physicians by enabling more accurate diagnosis or more reliable monitoring of therapy. Unfortunately, many new diagnostic technologies prove disappointing in practice, either because of limitations of the technology or because of a failure to address setting-specific issues that were not apparent during their evaluation. A recent systematic review of NPT in primary care has highlighted the methodological weaknesses of most published evaluations. There is a need for a formal statement of the criteria by which to judge the quality of evaluations in this field. In a similar fashion to Wilson and Junger's criteria for screening, seven questions need to be addressed. These cover the performance, reliability and acceptability of the test, its impact on decision-making, comparison with existing practice, cost-effectiveness of the test and integration with the practitioner's knowledge base. Evaluations of NPTs should therefore address the following methodological issues: demonstration of the need for the NPT, definition of the appropriate reference standard, calculation of sample size based on modelling of the decision problem and defining acceptable limits to the likelihood ratio, avoidance of verification bias, selection bias and treatment paradox, testing for the presence of spectrum bias, reporting the sensitivity of the results to changes in setting or prevalence or disease and calculating cost-effectiveness.     

Intrauterine contraceptive device use in patients with acute salpingitis

The frequency of intrauterine contraceptive device (IUD) use among 144 hospitalized women with acute salpingitis was compared with that of 229 control women, who were symptomless sexual partners of men examined for non-gonococcal urethritis. The relative risk for salpingitis was higher for IUD than in the group of basal level of disease (p < 0.02). This was mostly caused by the high relative risk in the women with no deliveries. Oral contraceptives showed a contrary picture, the relative risk was significantly lower than on the basal level (p < 0.01). Non-gonococcal and gonococcal infections were equally represented in salpingitis patients with IUDs. The severity of the infection in IUD users did not differ from that of non-IUD users.     

Intrauterine contraceptive device discontinuation among Jordanian women: rate, causes and determinants

OBJECTIVE: To determine the intrauterine contraceptive device (IUD) discontinuation rate and its causes and related factors among women attending UNRWA health centres in Jordan. METHODS: The study cohort comprised 371 women who had an IUD inserted during 1997 and who were interviewed during their visits to the health centres in the period January-March 2003. The main outcome measure was IUD discontinuation. RESULTS: The incidence of IUD discontinuation in the first year following insertion was 17.5%. Approximately 32% of the study sample continued using their devices after 5 years. The average duration of IUD use was 36 months. Of the 371 women, 39.6% discontinued IUD use because of a desire to conceive, 18.6% because of side effects, 4.9% because they were sexually inactive and 1.6% because of opposition from the woman's family. The most common side effects reported as reasons for discontinuation were bleeding, infection and pain. Discontinuation was inversely related to current age, marital age and number of living children. Outside camp residents, previous contraceptive users and women with obstetric complications were significantly less likely to discontinue IUD use. CONCLUSIONS: The crude cumulative rate of IUD discontinuation was 17.5% during the first year, suggesting a need to tackle the problem of discontinuation through effective educational strategies on the process of fertility and contraception. The most common reason for voluntary IUD removal was the women's desire to conceive. This suggests that improved counselling and good selection of candidates before IUD insertion is required.