Genital tract infections associated with the intrauterine contraceptive device can be reduced by inserting the threads into the uterine cavity.

OBJECTIVE: To study the influence of the position of the threads of an intrauterine contraceptive device (IUCD) on the development of genital tract infection. DESIGN: A multicentre randomized controlled trial. SUBJECTS: Women requesting an IUCD. INTERVENTIONS: The women were randomized to be fitted with an IUCD either with the threads contained in the uterine cavity (threads-up group) (n = 208) or passing through the cervix to the vagina in the usual way (threads-down group) (n = 237). Multiple centre study with follow-up at three months, 1 and 2 years. At the final visit 'missing' threads were retrieved using a disposable instrument (Retrievette). MAIN OUTCOME MEASURES: The occurrence of infection in the lower or upper genital tract. RESULTS: 63 women in the threads-up group and 78 in the threads-down groups dropped out. Previous gynaecological infection was reported by 21 and 48 women in the threads-up and threads-down group, respectively (odds ratio 0.44, 95% CI 0.24 to 0.79), 21 and 53 subjects had signs of infection at gynaecological examination (odds ratio 0.39, 95% CI 0.21 to 0.69) and a wet-smear was pathological in 33 and 79 (odds ratio 0.38, 95% CI 0.23 to 0.61). In the threads-up group the vaginal pH was also lower at the final check up after 2 years. Spontaneous descent of the threads occurred in 11% of the threads-up group and in six women in the threads-down group the threads were in the cervix. In 93 women the threads were easily retrieved by means of the Retrievette, four women insisted on the threads remaining in the uterus and in 18 thread removal was performed under local or general anaesthesia. CONCLUSIONS: Infectious complications in women using an IUCD are more frequent if the threads lead from the uterine cavity to the vagina. This problem can be reduced by inserting the threads so that they remain entirely within the uterine cavity, a feasible procedure now that an effective instrument for IUCD thread retrieval is available.

PIP: This study examined the influence of the position of the threads of an IUD on the development of a genital tract infection. Women who requested and IUD were part of this multicenter randomized controlled trial. These women were randomized to be fitted with an IUD either with the threads contained in the uterine cavity (threads-up group; n=208) or passing through the cervix to the vagina in the usual way (threads-down group; n=237). Followup occurred at 2 months, 1 year, and 2 years. At the final visit, missing threads were retrieved using a disposable instrument (Retrievette). 63 women in the threads-up group and 78 in the threads-down group dropped out and previous gynecological infection was reported by 21 and 48 women in the threads-up and threads-down group, respectively (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.24-0.79), 21 and 53 subjects had signs of infection at gynecological examination (OR 0.39, 95% CI 0.21-0.69), and a wet-smear was pathological in 33 and 79 (OR 0.38, 95% CI 0.23-0.61). In the threads-up group, the vaginal pH was also lower at the final checkup after 2 years. Spontaneous descent of the threads occurred in 11% of the threads-up group and in 6 from the other group, threads were in the cervix. In 93 women, the threads were easily retrieved by means of the Retrievette, 4 women insisted on the threads remaining in the uterus and in 18, thread removal was performed under local or general anesthesia. Infectious complications in women using and IUD are more frequent if the threads lead from the uterine cavity to the vagina. This problem can be reduced by inserting the threads so that they remain entirely within the uterine cavity, a feasible procedure now that an effective instrument for IUD thread retrieval is available.

Calcium and magnesium status in pregnant women. A comparison between treatment with calcium and vitamin C in pregnant women with leg cramps.

60 pregnant women underwent a double blind trial with calcium or ascorbic acid (1 g twice daily) as treatment for leg cramps. There was no significant difference between the two treatment groups with respect to clinical improvement. In 14 out of 60 patients the symptoms were totally abolished and in another 27 patients the symptoms were significantly decreased by the treatment (irrespective of drug used). In 17 patients the symptoms were unaffected while only two patients experienced an increase in frequency of their leg cramps during therapy. Serum total and ionized calcium concentrations, serum total magnesium and albumin concentrations were determined and were not significantly changed throughout therapy in any of the groups. No biochemical differences were found between the different treatment regimens or between those patients relieved or not relieved of their symptoms. Serum magnesium concentrations were at or just below the lower normal limit (for non pregnant women) in treated women and pregnant controls.

A solution to the problem of "missing" IUD threads.

A disposable, plastic, sterile instrument, RetrievetteR, for the retrieval of 'missing' threads of intrauterine contraceptive devices (IUD) at routine gynecological investigations was developed and tested in 80 patients. In 64 instances, the threads were found and easily drawn out through the cervical canal. In the remaining 16 cases, where the threads were not found, this was due to already expelled IUD in 6, too short threads in 5, inverted IUD in one, IUD which had partly perforated the uterine wall in one, unknown factors in 2 cases where the women chose to keep a correctly placed IUD in spite of missing threads and, finally, in only one case due to method failure. In the latter case, a correctly placed IUD with threads of normal length was later extracted under general anaesthesia. It is concluded that this instrument can help the physician avoid more complicated and unpleasant procedures with ultrasonic or X-ray localization and subsequent IUD extraction under local or general anesthesia in women with missing IUD threads.

Effects of sex hormone binding globulin capacity and pregnancy zone protein of treatment with combinations of ethinyl-oestradiol and norethisterone.

Sex hormone binding globulin (SHBG) and pregnancy zone protein (PZP) are two highly oestrogen-inducible serum proteins. SHBG capacity and PZP level were measured in 49 women treated with three different combinations of ethinyloestradiol and norethisterone. SHBG capacity and PZP were measured before and after 6 mth of treatment and both serum factors significantly increased during treatment for all three groups. PZP induction was found to be more sensitive and mainly to reflect the oestrogen component of a combined preparation while SHBG capacity was more sensitive to the modulating effect of the progestogen.

Social and psychological factors associated with long-term use of the pill and the IUD:.

PIP: This study examines the social and personality factors which affect women's decision to use oral contraceptives (OCs) or IUDs consistently for a long period of time. 130 women who had been using the pill (n=65) or the IUD (n=65) for more than 3 years were administered questionnaires (23 questions in all) covering socioeconomic background data, the present use of contraceptives, and some aspects of the information they had received about the methods. The Eysenck Personality Inventory (EPI) and the Cesarek Marke Personality Schedule (CMPS) were also administered. The EPI measured neuroticism and extroversion while the CMPI measured 11 of the psychogenic needs suggested by Murray (achievement, affiliation, aggression, defense of status, guilt feelings, dominance, exhibition, autonomy, nurturance, order, and succorance). The social data were compared with data from a group of women who were repeat aborters with a high failure rate regarding use of contraceptives and a group of 118 pregnant women who intended to deliver. The CMPS data were compared with previous data from 42 women applying for abortion and 44 pregnant women intending to deliver. Chi-square and t-test were used in statistical analysis. As a group, the long-term users are socially well-established women, have a stable relationship with a partner, have quite a few children, are well educated, are established professionally either as housewives or employees, have had a wide experience of various contraceptives, and also have a low incidence of earlier legal abortions. The EPI and CMPS data show that the long-term users as a group of women are psychologically very stable and have a low neurotic potential. All age groups between 20 and 50 favored the use of OCs while those aged 30 to 45 preferred the IUD. Attempts to increase continuation in contraception should consider the effectiveness and clinical safety of contraceptive methods as well as the social and psychological roles of sexuality and childbearing.^ieng

Changes in central circulation in premenopausal women during application of an estradiol valerate-norgestrel combination (Cyclabil).

The orthostatic circulatory reaction, the physical working capacity on a bicycle ergometer, the indirectly measured blood pressure at rest and after the ergometer test, the total hemoglobin content, blood volume and the heart volume in supine position were all determined on three separate occasions in the 17 premenopausal women who were taking an estrogen-progestogen combination as premenopausal substitution (2 mg estradiol valerate and 0.5 mg norgestrel, CyclabilR, Schering AG). Twelve women not receiving steroid treatment served as controls. The examinations were performed once prior to the commencement of the medication and 6 and 12 months thereafter. The orthostatic pulse reaction, the physical working capacity, the total amount of hemoglobin and heart volume did not change during the 12 months. Heart volume increased in both groups but there was no difference between the groups. Systolic and diastolic blood pressure increased slightly in the treated group during the first months but returned towards the initial values at 12 months. The transitory blood pressure increase when using the estrogen-progestogen combination in the premenopause during 12 months is similar to that earlier reported in younger women taking low-dose steroid contraceptives (8). It is conceivable that an adaptative mechanism in the vascular system will work in both situations.

[Women applying for legal abortions and their male partners]. / Abortsökande kvinnor och deras män.

PIP: 91 women who underwent abortion and their partners were interviewed about various factors related to the abortion. 45% of the women and 53% of the men were between 20 and 29 years of age. 49% were married, 21% were living together. 58% of the women and 65% of the men had higher educations. 53% of the women and 64% of the men worked outside the home. 62% had no children. In 42% of the cases, the partners had known each other longer than 3 years. In only ca. 10% of the couples were their relationship and their sex life rated as "poor". Communication was considered "good" in 80% of the partnerships. In 72% of the cases, both partners took responsibility for contraception and 76% discussed the matter together. 75% had used the condom, 47% oral contraceptives, and 31% the IUD. Nearly half of the women reported that the decision to undergo abortion had been made bilaterally. Socioeconomic reasons, family planning, and the desire not to have many children were the 3 most frequent reasons for undergoing abortion. In 63% of the cases, the abortion had no effect on a couple's relationship, and in 65% of the cases, the man had supported his partner throughout the abortion episode.^ieng

Prognostic value of the pregnancy zone protein during early pregnancy in spontaneous abortion.

The concentration of pregnancy zone (PZ) protein in maternal serum during early normal pregnancy was followed in a prospective study of 261 pregnant women. A marked increase which followed an exponential function was found and a theoretic onset of induction at the time for implantation was calculated. Women with a later spontaneous abortion had low values. The prognostic relevance of PZ determinations was studied and values from women who later had a spontaneous abortion were compared to those from normal pregnancies. The prognostic value of PZ protein was compared to that of hCG and progesterone. PZ and hCG assays had the same prognostic accuracy concerning the outcome of pregnancy while determinations of progesterone were less valuable.

Vacuum aspiration at therapeutic abortion: blood loss at operation in multigravid women.

Therapeutic abortion by vacuum aspiration in the first trimester was carried out on 129 healthy multigravid women. The loss of haemoglobin at operation was estimated and the volume of blood calculated. The figures were compared to those in a group of primigravid women earlier reported. Blood loss increases with gestational length. Blood loss at first trimester abortion is smaller in multigravid than in primigravid women. In multigravid women blood loss is not significantly influenced by the woman's age and the number of pregnancies.

PIP: To test the hypothesis that previous pregnancies may influence blood loss at vacuum aspiration (VA), a standardized operative technique and determination of blood loss was used in a group of multigravid women. The blood loss at their operations was compared with that lost in a group of primigravid women studied earlier. Therapeutic abortion by VA was carried out in the first trimester of 129 healthy women requesting pregnancy termination. In terms of loss of hemoglobin and calculated blood volume, there was an increase in blood loss with the duration of pregnancy. The difference between early (8-10 weeks) and late (11-13 weeks) trimester was statistically significant. There were no significant differences between individual weekly periods. The mean blood loss for the whole first trimester (8-13 weeks) was 92 ml (range, 9-432 ml), corresponding to a mean hemoglobin loss of 11.9 g. In terms of age groups, blood loss seemed to decrease with increasing age and with increasing numbers of pregnancies, though not significantly. The total amount of hemoglobin was lower 2 weeks after the therapeutic abortion than before (407 vs. 428 g); however, there was no correlation between the volume of blood lost at operation and this decrease. When these figures were compared with those in a group of primigravid women, blood loss at first trimester abortion was less in multigravid than in primigravid women. In multigravid women, blood loss was not significantly influenced by the woman's age and number of previous pregnancies.

Vacuum aspiration at therapeutic abortion: influence of two different negative pressures on blood loss during and after operation.

In 167 women blood loss was measured during and after vacuum aspiration for therapeutic abortion in the first trimester of pregnancy. Two different negative pressures were used -49.1 kPa (-0.5 kp/cm2) and -78.5 kPa (-0.8 kp/cm2) in a randomized series. It was found that for the whole first trimester (8--13 weeks) blood loss during and after operation was relatively small and not influenced by the pressure used. In no case blood loss exceeded 500 ml at operation or 60 ml during the first post-operative week. In 6 women post-operative infections were diagnosed.

The effect of oxytocin on hypertonic saline abortion.

Oxytocin was infused in 22 randomly selected pregnant women after extraamniotic hypertonic saline instillation. In another 24 pregnant women no oxytocin was infused at midtrimester abortion. There was no difference between the two groups in mean time from saline injection to expulsion of the fetus.

A quantitative study of the pregnancy zone protein in sera of woman taking oral contraceptives.

By means of a single radial immunodiffusion the concentration of "the pregnancy zone protein" (PZ) was measured in sera from women taking oral contraceptive drugs. Woman taking only 0.3 mg. of norethisterone were found not to induce measurable amounts of PZ, whereas women taking combined contraceptive drugs showed a significant rise in concentration of PZ. After six months' treatment, 1 mg. of norethisterone and 0.1 mg. of meastranol daily were found to give an average concentration of PZ amounting to 59 mg. per 100 ml., that is, approximately half of the concentration of PZ in sera from women during the last trimester of pregnancy. Different combined contraceptive pills gave rise to different concentrations of PZ.

PIP: The serum concentrations of pregnancy zone protein (PZ) were measured by means of a single radial immunodiffusion test in 322 blood samples from 103 women, drawn prior to and during treatment with oral contraceptives (OCs), in order to study the level of PZ in relation to the composition of the OC drugs. 80 women never having been pregnant or treated with OCs were divided into 2 groups: 22 treated with a combination of 1 mg norethisterone and .1 mg mestranol (norinyl + 100) and 58 treated with .5 mg nogestrel and .05 mg ethinyl estridiol (Ovral). A 3rd group of 23 women were examined during treatment with low-dose progestin contraceptives, .3 mg norethisterone. 54 of the 80 women taking combined OCs showed elevated PZ (less than 10 mg/100 ml). In the remaining 26 and progestin-treated patients, PZ levels remained the same. 91% of women taking Norinyl + 100 had an elevated response while 59% of women taking Ovral showed a similar response. Women taking Norinyl + 100 had higher mean values for the concentration of PZ as well. The significance of difference after 1, 3, and 6 months was p less than .05 for each month. In both groups the increase in PZ values was most pronounced during the 1st month of treatment. The concentration of PZ in patients taking OCs is approximately half the value of the last trimester of pregnancy. There is also individual variation in the ability to produce PZ.

Blood loss in therapeutic abortion by vacuum aspiration in multigravidae.

PIP: To determine blood loss in 129 multigravidae undergoing first-trimester abortion by vaccum aspiration, hemoglobin was measured in the aspirate and calculated. Total hemoglobin was measured before and 2 weeks after the operation. Mean age of the patients was 29.6; mean duration of pregnancy was 11 weeks (range, 8-13 weeks). Blood loss averaged 64 + or - 48 ml in women 8-10 weeks pregnant, 107 + or - 82 ml in 11-13 weeks pregnant. Overall, the mean was 92 + or - 74 ml. Hemoglobin loss was 8.4 + or - 6.3 gm for those 8-10 weeks pregnant, 13.9 + or - 10.3 gm for those 11-13 weeks pregnant, and 11.9 + or - 9.5 gm overall. Loss of blood in multigravidae was less than that shown by primigravidae in an earlier study. Blood loss was not significantly affected by age or parity. Total hemoglobin was lower 2 weeks after the oepration than before, but this may have been due to aphysisiological reasction, since the decline did not correlate with blood loss at the time of abortion.^ieng

Influence of pressure on blood loss in therapeutic abortion by vacuum aspiration.

PIP: To compare the effect of different negative pressures (49.1 and 78.5 kPa) on blood loss during and after vacuum aspiration, blood loss was measured in 167 women undergoing first-trimester abortion who were randomly assigned to 1 of the 2 pressures. Blood loss was also measured for 4 hours after the operation. 33 women measured blood loss over the whole 1st postoperative week. At both pressures, operative blood loss was greater at 11-13 weeks of pregnancy than at 8-10 weeks; there was no difference between the pressures, and no blood loss exceeded 500 ml. Immediate postoperative blood loss (4 hours) was the same at both pressures; at 11-13 weeks, it was significantly (p .01) greater when the greater pressure was used. Overall (8-13 weeks of pregnancy) there was no significant difference between the pressures. The total postoperative blood loss (7 days) did not differ between pregnancy durations or pressures; in no case did it exceed 60 ml. No conclusive statemnt can be made on which pressure is preferable.^ieng