Epidemiology of ectopic pregnancy during a 28 year period and the role of pelvic inflammatory disease.

OBJECTIVES: We analysed the epidemiology of ectopic pregnancy (EP) during a 28 year period, 1970-97, using methods applicable to ecological studies in order to test the hypothesis that a reduction of pelvic inflammatory disease (PID) will be associated with a decrease of EP. METHODS: Hospital records of patients aged 15-54 admitted to our department of gynaecology were reviewed for EP and PID for the period 1 January 1970 to 31 December 1997. EP for the period 1970-4 was based on available statistics. The total number for EP was 1270 and for PID 2559. The total population for the catchment area was 100,000-120,000 during the study period. Incidences were age standardised and calculated using official population statistics to represent the average female population in the five 5 year periods 1970-4, 1975-9, 1980-4, 1985-9, 1990-4, and in each of the consecutive years 1995, 1996, and 1997. Incidences for EP were calculated per 1000 women and per 1000 pregnancies while those for PID per 1000 women. National statistical data of EP were available for 1975-94 and were used for comparison with the local study. RESULTS: The EP incidences increased from 7.7 per 1000 pregnancies in the first 5 year period to 13.4 in the second, and continued to rise for another decade reaching the peak figures of 16.6 in 1985-9--that is, more than a twofold increase. Since then and to 1997 the EP incidence has decreased by 30%. PID admissions increased during the study period from 2.7 per 1000 women in the first 5 year period to 3.2 in the second. From then on they continuously decreased and reached a low of 0.5 in 1997. The greatest changes occurred in women < or = 24 years of age. The peak incidence for this age group was 7.7 in 1975-9, and the lowest was 0.4 per 1000 women in 1996. The greatest reduction of EPs was noted for women < or = 24 years old, from a high of 10.0 in 1975-9, coinciding with the peak incidence of PID, to a low of 4.0 in 1997, a reduction of 58.4%. The incidence of EP was two to three times higher in women > or = 25 years old, most obvious in those > or = 30 years, with peak figures of 20.9 per 1000 pregnancies in 1985-9, and 13.9 in 1997, a reduction of 33.4% and the lowest figures for the past 23 years. For women aged 25-29 years the incidence peaked in the previous 5 year period 1980-4--that is, one 5 year period later than for those < or = 24 years, which we interpret as cohort effects in relation to PID. CONCLUSIONS: Reduction of PID was strongly associated with a decline of EP. The decline was greater and immediate for women < or = 24 years old, than for those > or = 25 years. The two to three times higher EP incidence in women > or = 25 years of age was most probably due to a cohort effect as the peak of PID occurred a decade earlier in women < or = 24 years old. Prevention of PID may not only reduce EP but also reduce adverse effects on tubal patency.

Swedish fathers' involvement in and experiences of childbirth preparation and childbirth.

OBJECTIVE: To discover the expectations and experiences of childbirth preparation and childbirth of Swedish men in order to contribute to a basis of reflections in the midwifery profession. DESIGN: Three tape-recorded interviews were performed: before and after childbirth preparation, and between one and three weeks after the baby was born. SETTING: Swedish maternity care. PARTICIPANTS: Eleven men who participated with their partners in antenatal classes. MEASUREMENTS AND FINDINGS: The interviews were analysed in several steps and included co-assessments by co-workers. Finally, an interpretation based on the concept 'vital involvement' was undertaken. Indications of vital involvement as well as various levels of involvement or distance were found. The participation in childbirth was more demanding than expected for the eleven men. They felt unprepared for an unpredictable process, the experience of time and pain, the woman's action, and their own reactions. The men who were regarded by the authors as vitally involved seemed to manage overwhelming feelings of helplessness during childbirth, to support the women, and experience the meeting with the baby positively. KEY CONCLUSION: It seems important for midwives to meet men individually, design childbirth preparation from men's perspective, follow up interpretations of the content, discuss expectations with regard to the men's role, and assess their experiences during the birth process.

Decreasing incidences of gonorrhea- and chlamydia-associated acute pelvic inflammatory disease. A 25-year study from an urban area of central Sweden.

BACKGROUND AND OBJECTIVES: Acute pelvic inflammatory disease (PID) affects women in their reproductive years and is often a complication of a sexually transmitted disease (STD), particularly Neisseria gonorrhoeae and Chlamydia trachomatis. Infertility, ectopic pregnancy, and chronic lower abdominal pain are common long-term sequelae to acute PID. Through different preventive measures, endemic N. gonorrhoeae is almost eliminated, and C. trachomatis has been reduced almost fourfold in Sweden. GOALS: To investigate variations in STD-associated acute PID and the extent to which this influenced the yearly incidences of patients hospitalized for this complication during a 25-year-period. STUDY DESIGN: Hospital records of 2499 patients admitted and treated for acute PID from January 1, 1970 to December 31, 1994 were analyzed for infection with N. gonorrhoeae. Routine laboratory diagnosis for C. trachomatis infection started June 1, 1980. Detailed statistical analysis for chlamydial-associated PID in this study, therefore, covers the period January 1, 1981 to December 31, 1994 and includes 1030 patients. RESULTS: Gonorrhea occurred in 42% of patients with acute PID in 1970 and decreased continuously to zero in 1988 and beyond. Concomitant urogenital chlamydial infection reduced almost fourfold from 28.4% in 1985 to 7.7% in 1994. Yearly admissions for acute PID fluctuated slightly (< or = 16%) in the early 1970s and early 1980s but increased greatly (> 60%) in the middle and late 1970s; the highest was 180 per year in 1976. This coincided with high incidence rates of gonorrhea in the general population, and probably of genital C. trachomatis infection as well, coupled with an increased use of intrauterine contraceptive device in nulliparous women. The largest increase in admissions for acute PID was in the 15- to 29-year-old group. A steady decrease started in 1987 and reached the low figure of 26 admissions in 1994. The greatest decrease occurred in the 15- to 19-year-old group, from the relative age distribution of 28.9% in the period 1970 to 1974 to 12.9% in 1990 to 1994. Yearly admissions for the > or = 35-year-old group remained almost constant during the study period, but the relative age distribution shifted from second lowest (excluding those 14 years or younger, totaling 15 admissions for the entire study period), 9.1% at the beginning of the study period, to the second largest, 24.9% at the end of it. The study also showed that the total and relative rates of recurrence decreased. CONCLUSIONS: Measures aimed at reducing incidences of gonorrhea and genital chlamydial infection will reduce the incidences of one of the most serious complications of these STDs, acute PID, and, in turn, its long-term sequelae.

Women's perceptions of childbirth and childbirth education before and after education and birth.

OBJECTIVE: to illuminate women's perceptions of childbirth and childbirth education before and after education and birth. DESIGN: qualitative, using tape-recorded interviews to collect data. Interpretation was performed from Antonovsky's concept sense of coherence. SETTING: childbirth education, a part of parent education in Sweden. PARTICIPANTS: eleven women expecting their first child, where the pregnancy was planned and normal MEASUREMENTS AND FINDINGS: the development of perceptions of childbirth and childbirth education was described. The women adopted the content of the education in different ways. Fear as well as unreflected knowledge seemed to block acquisition of new knowledge. Factors which contributed to a childbirth experience worse than expected were lack of or inconsistent information. Increased knowledge about childbirth and experiences of confirmation during childbirth contributed to a good or better experience than expected. KEY CONCLUSION: any model of childbirth education which does not take into consideration the individual woman's perceptions of childbirth and childbirth education seems to be inadequate. IMPLICATIONS FOR PRACTICE: the findings stress the importance of individual assessment of expectations of and experiences of childbirth education. Consistency in information given before and during childbirth supports a sense of comprehensibility, manageability and meaningfulness.

Treatment of cervical-carcinoma by wertheim-meigs surgery - long-term follow-up results in a well-defined Swedish region.

In a retrospective analysis of a complete geographic series of cervical carcinomas treated by Wertheim-Meigs radical surgery, a number of important prognostic factors were evaluated and long-term survival data are presented. In all, 367 women with FIGO stage I-II tumors were included. The main histopathologic types were squamous cell carcinoma in 84% and adenocarcinoma in 12%. The mean age of the patients was 42.5 (range 19-68) years. In 125 women (34%), adjuvant radiotherapy was administered pre- or postoperatively. The median period of follow-up was 12 (range 2-27) years. In 88% of the specimens surgery (93% in stage I and 66% in stage II) was classified as radical with regard to the excision margins. This was an important and highly significant prognostic factor. If the margins were wide and free of tumor, the 10-year survival rate was 93%, but if margins were infiltrated by the tumor, the survival rate was 14%. Pelvic lymph node involvement was recorded in 52 cases (14%). The frequency of lymph node spread was associated with tumor stage (IA O%, IB 14%, IIA 32%). The probability of survival of the complete series was 93% at 5 years and 84% at 10 years. In cases of lymph node involvement, the 10-year survival rate was 57%. The preoperative tumor stage had a highly significant influence on long-term tumor-specific survival. Tumor grade was also a significant prognostic factor, but not the histologic type (squamous, adenosquamous, or adenocarcinoma). Age and parity were also insignificant prognostic factors. The tumor recurred in 59 cases (16%). The mean time to relapse was 28 months. The 10-year survival was 29% for this group of patients. Peroperative complications were recorded in 50 patients (14%). Excessive bleeding (11%) and urinary tract injuries (3%) were most frequent. Postoperatively, 101 patients (28%) had some kind of complication associated with the surgical procedure. Surgical complications were more frequent among women over 50 years of age. Bladder dysfunction (11%) and obstruction of the ureter (8%) were recorded most frequently. In 19 cases (5.2%), urinary tract or intestinal fistulas were diagnosed during the period of follow-up. With increasing experience of the surgeons and fewer stage II tumors, the frequency of fistulas associated with the surgical procedure decreased to 2.4% during the latter part (1975-90) of the period. Adjunctive postoperative radiotherapy increased the risk of late complications. In 8 cases (6.4%), serious complications associated with the combination of surgery and radiotherapy were reported.

Gonorrhea, genital chlamydial infection, and nonspecific urethritis in male partners of women hospitalized and treated for acute pelvic inflammatory disease.

BACKGROUND AND OBJECTIVES: Acute pelvic inflammatory disease (PID) is often a complication to a sexually transmitted disease (STD), the most important agents being Neisseria gonorrhoeae and Chlamydia trachomatis. However, very little is known of the genitourinary status of the male partners of women with acute pelvic inflammatory disease (PID). GOAL OF THIS STUDY: To determine the presence of N. gonorrhoeae and/or C. trachomatis infection or nonspecific urethritis (NSU) in regular sexual male partners of women with acute PID. STUDY DESIGN: Two hundred regular sexual male partners to 196 women admitted to a hospital for treatment of acute PID were referred by contact tracing to the sexually transmitted disease outpatient clinic for clinical and laboratory examination regarding N. gonorrhoeae and/or C. trachomatis infection, or NSU defined as the presence of > 5 polymorphonuclear leukocytes per high-power field (x1,000) in > 4 fields and with negative laboratory tests for N. gonorrhoeae and C. trachomatis. RESULTS: The majority of the males was in the age group 20 to 29 years of age, female sexual partners in 15 to 24 years years of age. N. gonorrhoeae was demonstrated in 42.9% of the male partners to women with acute PID and concomitant gonorrhea. The corresponding figure for C. trachomatis was 43.7%. Nonspecific urethritis was diagnosed in 26 (33.8%) of the male partners to 77 women were diagnosed with N. gonorrhoeae and/or C. trachomatis infection, and in 45 (37.8%) partners of 119 women without such an infection. In all, N. gonorrhoeae, C. trachomatis or NSU were demonstrated in 117 (59.7%) of the 196 male partners, but only 32% of the males with N. gonorrhoeae or C. trachomatis and 8.5% of those with NSU presented subjective symptoms of urethritis. CONCLUSION: The findings of the study stress the need for routine clinical and laboratory examination and treatment of sexual male partners to women with acute PID.

The disposal of the aborted fetus--new guidelines: ethical considerations in the debate in Sweden.

During the 70s and 80s ethical debate concerning the fetus became intensive. The great advances made in medical technology and research and improvements in prenatal diagnosis as well as in embryological research have led us to believe that the fetus is an individual with recognised claims to protection. In Sweden the aborted fetus has previously been considered merely as a risk-disposal problem, equivalent to dangerous and infected material and there have been no specific guidelines for the treatment of the fetus after abortion. In July 1990 treatment of aborted fetuses was changed with the general guidelines from the National Board of Health and Welfare. The present paper sets out the main contents of the guidelines and discusses the gradually changing views concerning the status of the human fetus in Sweden, as well as the public debate which has been a contributing factor to these changes.

Neisseria meningitidis in specimens from urogenital sites. Is increased awareness necessary?

Neisseria meningitidis serogroups B type 2 and Y were isolated from urogenital specimens from three heterosexual patients. The first patient was a young man with the clinical signs and microscopic findings of a typical gonococcal urethritis. The second was a middle-aged woman with cervicitis, in whom neither Neisseria gonorrhoeae nor Chlamydia trachomatis were demonstrated by culture. In the third patient, a young woman, N. meningitidis was associated with cervicitis, acute salpingitis, and peritonitis. The patients' clinical symptoms responded quickly to antibiotic treatment. Meningococci of the same serogroup/serotype as the index cases were demonstrated in two of the sexual consorts in pharyngeal specimens but not in genitourinary specimens. Orogenital sexual practice seemed to be the most likely route of transmission. During the period of this study (August 1989-March 1990), the three meningococcal strains observed at the authors' laboratory represented 20% of the total number of urogenital isolates of pathogenic Neisseria. A greater awareness of this problem from medical, diagnostic, epidemiologic, and legal viewpoints is therefore needed.

Epidemiology and aetiology of acute non-tuberculous salpingitis. A comparison between the early 1970s and the early 1980s with special reference to gonorrhoea and use of intrauterine contraceptive device.

More patients were hospitalised for acute salpingitis at the Department of Obstetrics and Gynaecology, Orebro Medical Centre, Orebro, Sweden, during the 5 year period 1970-1974 (period I) as compared with that of 1980-1984 (period II), 666 patients and 524 respectively, a decrease of 22%. The majority of cases, 92% in period I and 85% in period II, occurred among women 15-34 years of age, that is a relative increase of patients aged over 34 from 8% in period I to 15% in period II. Concomitant urogenital gonorrhoea occurred in 26.2% of the patients in period I compared with 12.0% in period II, a highly significant decrease (p less than 0.001) mainly confined to the age group 15-24, whereas there was no relative difference for the two periods in the age group 25-34 years. The number of patients using intrauterine contraceptive device (IUCD) was 96/666 (14.4%) in period I compared with 113/524 (21.6%) in period II (p less than 0.001). There were also relatively more IUCD users among the patients with gonorrhoea and acute salpingitis in period II (15.5%) compared with period I (10.4%) but this difference was not statistically significant. From 1981 to 1984 370/424 patients were cultured for Chlamydia trachomatis and 27.8% (103/370) were positive. Thus Chlamydia trachomatis is at present, at least in the Orebro area, the most frequently isolated STD agent among acute salpingitis patients while gonorrhoea is of much less importance.

Diagnosis of urogenital gonorrhoea by detecting gonococcal antigen with a solid phase enzyme immunoassay (Gonozyme).

A solid phase enzyme immunoassay (Gonozyme) was used to demonstrate gonococcal antigen in urogenital specimens. Urethral specimens from 101 men and cervical specimens from 150 women were examined, and the diagnostic yields were compared with those obtained by culture. The Gonozyme test was positive in 25 patients, 15 men and 10 women, and negative in 226 patients. Gonococci were isolated by culture in 23 of the patients, 12 men and 11 women. The Gonozyme test gave false-negative results in two men and one woman patient. The sensitivity of the test was 87% for the men and 91% for the women. Correspondingly, the test specificity was 94.3% for the men and 100% for the women, the predictive value of positive test 80% and 100%, and that of negative test 97.7 and 99.3% respectively. The Gonozyme test does not allow antibiotic sensitivity testings but has the advantage of rapidity and is not dependent upon viable organisms. The test is an attractive alternative to culture procedures for screening women patients with symptomatic or asymptomatic gonorrhoea.

Antibiotic treatment of acute salpingitis. A study of plasma concentrations of two tetracyclines (doxycycline and lymecycline).

A group of 782 patients with a diagnosis of acute salpingitis (a few of the patients because of other infection in the pelvis) were treated with the recommended oral dose of doxycycline (200 mg the first day and 100 mg once daily for at least the following 9-12 days) in combination with 1 g benzyl penicillin and 0.6 g procaine penicillin twice daily intramuscularly for 5-7 days. The plasma concentrations of doxycycline were determined on the third day of treatment before the next dose was given. In 26.5% of the patients the concentrations were below 1 microgram/ml plasma, considered as the minimum therapeutic level. The dose of doxycycline was increased to 200 mg a day in these patients and the plasma concentrations increased accordingly. In another group of 80 patients, 40 were treated with the standard doxycycline dose, and the other 40 patients with the standard lymecycline dose (300 mg twice a day). The plasma concentrations, determined before the dose on the third day, were below 1 microgram/ml in 35% of the patients treated with doxycycline, and in 5% of those treated with lymecycline. Since acute salpingitis in most cases is a serious complication to a lower genital tract infection, often a sexually transmitted disease caused by tetracycline-sensitive organisms, the importance of achieving and determining the therapeutic plasma concentrations of tetracyclines is stressed.

In vitro studies of the adherence of Neisseria gonorrhoeae and other urogenital bacteria to vaginal and uroepithelial cells, with special regard to the menstrual cycle.

The adherence to vaginal epithelial and uroepithelial cells of three serogroups (W/I, W/II and W/III) and their colony colour opacity variants of Neisseria gonorrhoeae were studied with regard to the menstrual cycle, using an in vitro test method. Vaginal epithelial cells obtained in the post-menstrual phase attach more gonococci than cells obtained in the pre-menstrual phase. This difference was statistically highly significant (p less than 0.001) for the three serogroups tested. The adherence rate also differed with regard to the three serogroups used in the tests (W/II greater than W/III greater than W/I), and with regard to organisms from opaque greater than transparent). There was no variation in the adherence of gonococci to uroepithelial cells during the menstrual cycle. E coli, S. saprophyticus and group B streptococci showed a tendency to increased adherence to vaginal epithelial cells in the post-menstrual phase compared with ther pre-menstrual one, but the difference was not statistically significant.

Adherence in vitro of Neisseria gonorrhoeae. Escherichia coli and group B streptococci to vaginal epithelial cells of post-menopausal women.

The adherence of Neisseria gonorrhoeae, Escherichia coli and group B streptococci to vaginal epithelial cells from post-menopausal women was studied by an in vitro test system. It was found that the adherence rate of gonococci to vaginal cells from women on oestrogen treatment was statistically significantly higher (p less than 0.001) as compared to those without such a treatment. No increased adherence was found for E. coli and group B streptococci. The cellular and functional bases of these findings are discussed.

Variations in attachment of Neisseria gonorrhoeae to vaginal epithelial cells during the menstrual cycle and early pregnancy.

An in vitro system was used to study the ability of virulent gonococci to adhere to vaginal epithelial cells obtained from healthy donors during the pre- and postmenstrual phases, and from those in early pregnancy. It was found that more gonococci adhered to the cells from donors in the postmenstrual phase than to cells from those in the premenstrual one. This difference was statistically highly significant. The attachment rate of gonococci to vaginal epithelial cells was similar in early pregnancy and in the premenstrual phase.