Hormonal and barrier contraception and risk of upper genital tract disease in the PID Evaluation and Clinical Health (PEACH) study

OBJECTIVE: Among women diagnosed with pelvic inflammatory disease, we examined the associations between hormonal or barrier methods of contraception and upper genital tract infection or inflammation. METHODS: Participants were 563 patients from a treatment trial for pelvic inflammatory disease. All had pelvic pain; pelvic organ tenderness; and leukorrhea, mucopurulent cervicitis, or untreated cervicitis. Contraceptive use within the prior 4 weeks was compared among women with baseline upper genital tract gonorrhea or chlamydia, women with endometritis without upper genital tract gonorrhea or chlamydia, and women with neither upper genital tract gonorrhea or chlamydia nor endometritis. RESULTS: Inconsistent condom use was significantly and independently associated with a 2 to 3 times elevated risk for upper genital tract infection. Upper genital tract gonorrhea or chlamydia was not significantly associated with use of oral contraceptives, use of medroxyprogesterone, condoms used consistently, nor other barrier methods. CONCLUSION: No hormonal or barrier contraceptive method was related to a reduction in upper genital tract disease among women with clinical pelvic inflammatory diseases.     

A randomized comparison of propofol and methohexital as general anesthetics for vacuum abortion

The objective of this study was to determine whether propofol and methohexital differ in their efficacy, acceptability, cost and side effects when used as the single anesthetic agent for inducing general anesthesia in first-trimester vacuum abortion. We randomized 400 unpremedicated American Society of Anesthesiologists grade I-II women to receive 1% propofol or 1% methohexital by intravenous bolus infusion during abortion. No ancillary anesthetic or adjunctive drugs were used. Visual analogue scale scores were used to grade preoperative patient anxiety and the quality of the anesthetic experience. All personnel outside the operating suites, except the data analyst, were blinded. Chi2, median, analysis of variance and Student's t-tests were used, as appropriate. There were no statistically significant differences in age, gravidity, parity, spontaneous and induced abortion, body mass index or gestational age. Mean total operating time and total drug dose were similar. Propofol use resulted in a significant reduction in the incidence of postoperative nausea (11.5% vs. 17.5%) or vomiting (3.5% vs. 7.0%) with a combined p (mean difference) = 0.002 (95% confidence interval of the mean difference 1.8%, 17.2%). Both the nursing and patient appraisals of the quality of the anesthetic experience favored propofol, but only the nursing scores reached statistical significance (p < 0.001). The cost differential was more than twofold greater for propofol patients, 9.51 dollars vs. 4.42 dollars. In our population of midwestern patients in a major urban area, propofol use had modest advantages over methohexital when used as single agents as judged by first recovery charge nurses, but patients found them equally acceptable.     

Progesterone, inhibin, and hCG multiple marker strategy to differentiate viable from nonviable pregnancies

OBJECTIVE: To determine whether a combination of serum and urine biomarkers drawn from symptomatic pregnant women will help early differentiation of viable from nonviable pregnancies. METHODS: We conducted a prospective cohort study of 220 women who presented in the first trimester of pregnancy with complaints of pain, cramping, bleeding, or spotting. Serum samples for progesterone, inhibin A, and hCG, and urine beta-core hCG, were collected at presentation. To evaluate whether those biomarkers could predict viable and nonviable outcomes in pregnancy, we used likelihood ratios to compare operating characteristics of single and multiple biomarker strategies. RESULTS: Of 220 pregnancies studied, 98 were viable and 122 nonviable. Among single biomarkers, progesterone alone appears to have the greatest utility (area under the receiver operator characteristic curve = 0.923). Among dual-biomarker strategies, progesterone plus hCG and progesterone plus inhibin A improved specificity but not sensitivity. At 95% sensitivity, the combination of progesterone and hCG improved specificity from 0.29 to 0.66 (improvement = 0.37 [95% confidence interval 0.23, 0.52]). A triple-biomarker combination did not show substantial improvement over the dual-biomarker strategy. Also, combinations that used urine beta-core hCG did not improve diagnostic accuracy. CONCLUSION: Serum progesterone appeared to be the single most specific biomarker for distinguishing viable from nonviable pregnancies. When a dual-biomarker strategy was applied, combining serum progesterone with hCG, specificity improved significantly, which suggests that a multiple biomarker strategy might help distinguish viable from nonviable pregnancies in early gestation.     

Patient satisfaction with laparoscopic Burch retropubic urethropexy

OBJECTIVE: To assess six-month and three- to four-year patient-oriented outcomes after laparoscopic Burch retropubic urethropexy. STUDY DESIGN: Twenty-two women with urodynamically proven genuine stress incontinence with urethral hypermobility underwent laparoscopic Burch retropubic urethropexy. Preoperatively, all 22 women completed a questionnaire concerning their incontinence. Postoperative measures of symptoms of incontinence, impact of incontinence on daily activities and patient satisfaction were assessed at six months and three to four years postoperatively. In those women who were followed, the questionnaire data at the three-time points (preoperative, six months and three to four years) were compared. RESULTS: Thirteen women (59%) completed postoperative questionnaires at six months and three to four years. When compared to preoperative data, there was a significant improvement in symptoms of stress incontinence at six months (P = .0005) and at three to four years (P = .002). There was also a significant reduction in limitations on daily activities at six months (P = .0005) and at three to four years (P = .0005) as compared to preoperative data. Twelve of the 13 women considered their surgery successful at six months and at three to four years. CONCLUSION: After laparoscopic Burch retropubic urethropexy, there was a significant improvement in patient-oriented outcomes, including complaints of incontinence and functional status.     

Marijuana Use among Young Women in a Primary Care Setting

OBJECTIVE To evaluate the prevalence of marijuana use among young women, ages 18–24, within a primary care setting. DESIGN From 2/05 to 12/05, women completed a brief, anonymous self-report screening instrument in two urban primary care clinics for potential participation in a randomized controlled trial of an intervention to reduce marijuana use and sexual risk-taking behavior. During the last few months of recruitment, women who completed the screening instrument were also asked to provide a urine sample to test for the presence of marijuana and other drugs. RESULTS Of the 607 women who completed the screening instrument, 38.6% reported lifetime marijuana use, 8.4% used marijuana at least monthly, and 1.7% reported using marijuana daily. Within this ethnically diverse sample (45% Hispanic), women who used marijuana at least monthly were more likely to smoke cigarettes (OR = 2.03, 95% CI = 1.04, 3.96), binge drink at least once a month (OR = 2.66, 95% CI = 1.34, 5.28), and to have ever used other drugs (OR = 2.91, 95% CI = 1.31, 6.45). Of the 67 urine samples provided, 60 (89.6%) were concordant with self-reported use, but six of the seven discordant samples were positive despite negative self-report. CONCLUSIONS The prevalence of marijuana use and binge drinking in this ethnically diverse sample of young, female primary care patients was lower than rates reported in national surveys. Providers should consider marijuana use as a part of a process that addresses more prevalent high-risk behaviors, bearing in mind that these behaviors may be underreported during routine screening.     

Strength of indication for cesarean delivery: comparison of private physician versus resident service labor management.

OBJECTIVE: Our purpose was to compare the strength of indication for cesarean delivery for 2 groups of patients who had undergone cesarean delivery-those treated by physicians in private or group practice and those treated by a clinic or resident service. STUDY DESIGN: From records of 119 cesarean deliveries performed in 1992, data concerning patient history, labor course and management, fetal monitor tracings, and indications for cesarean delivery were extracted, summarized, and presented to 3 reviewers. Each reviewer rated the strength of indication for cesarean delivery on a 10-point visual analog scale and specified how often they would have chosen an alternative management plan. Reviewers were blinded to the research hypothesis and to patient age, type of provider, and insurance status. RESULTS: Using a multivariate linear regression model to adjust for differences in age and indication for cesarean delivery, we found that strength of indication scores were higher among patients treated by a resident service than among those treated by private physicians (P <.0001) and that an alternative action plan was more often suggested for deliveries managed by private physicians (P <.0001). CONCLUSIONS: Among women who underwent cesarean delivery, the strength of indication judged by a panel of reviewers not involved with the patient's care was stronger among resident-treated patients than among cases treated by private physicians. Although there are several possible explanations, the findings may suggest that physicians in private practice use different criteria than do resident physicians for deciding to perform a cesarean.     

Oligohydramnios: a review

Oligohydramnios is a relatively common complication of pregnancy. Etiologies include congenital anomalies, intrauterine growth retardation, premature rupture of the membranes, drugs, postterm gestation and postmaturity. Sequelae from prolonged oligohydramnios including pulmonary hypoplasia and fetal compression syndrome can be devastating. Perinatal morbidity and mortality are both significantly increased in pregnancies complicated by oligohydramnios. Successful management requires a thorough search for the cause of the decreased amniotic fluid volume, and close antenatal surveillance.