Ruptura uterina espontánea e inadvertida. Reporte de caso / Spontaneous and undetected uterine rupture. Case report

Resumen ANTECEDENTES: La ruptura uterina es la separación de las tres capas del útero que se asocia con una cicatriz. La mayoría de los casos se relacionan con intento de trabajo de parto, después de una cesárea. La ruptura es una complicación grave, que pone en riesgo a la madre y al feto. De forma excepcional puede haber ruptura uterina sin síntomas, y el hallazgo se advierte durante la cesárea de repetición. CASO CLÍNICO: Paciente de 27 años, programada para cesárea de repetición por disfunción de una prótesis valvular. A la apertura de la cavidad abdominal no se encontró hemoperitoneo y se visualizó un defecto transverso en el segmento uterino inferior de las tres capas uterinas, con saco amniótico íntegro, coincidente con ruptura uterina. Se obtuvo un recién nacido sano, de 2610 g y Apgar de 9-9. La herida uterina se suturó en dos planos y se practicó la oclusión tubaria bilateral. La evolución durante el puerperio fue satisfactoria. CONCLUSIONES: La ruptura uterina puede pasar inadvertida por algún descuido en la historia clínica y ausculatación, de ahí la necesidad de ser más minuciosos para poder indicar el tratamiento adecuado.

Abstract BACKGROUND: Uterine rupture is a separation of the three layers of the uterus and is associated with a uterine scar. Most cases are related to an attempted labor after a cesarean section. Uterine rupture is a serious complication that puts both mother and fetus at risk. Exceptionally uterine rupture can occur without symptoms, being a finding during a repeat cesarean section. CLINICAL CASE: A 27-year-old patient scheduled for repeat cesarean section due to dysfunction of a prosthetic valve. Upon opening the abdominal cavity, no hemoperitoneum was found and a transverse defect was visualized in the lower uterine segment of the three uterine layers, with an intact amniotic sac, coinciding with uterine rupture. A healthy newborn was obtained, weighing 2610 g and Apgar 9-9. The uterine wound was sutured in two planes and bilateral tubal occlusion was performed. The evolution during the puerperium was satisfactory. CONCLUSIONS: Uterine rupture may go unnoticed due to an oversight in the clinical history and auscultation, hence the need to be more thorough in order to indicate appropriate treatment.

Prevalence, concordance and reproductive sequelae after Chlamydia trachomatis infection in Mexican infertile couples.

There are few concordance studies on the Chlamydia trachomatis (infection among infertile couples. The objective of this research was to know the prevalence, concordance and reproductive sequelae that couples may develop when both partners show a C. trachomatis infection. A cross-sectional study among 688 infertile couples using the C. trachomatis detection by real-time PCR was performed. The infertility causes were obtained from their medical records. The prevalence of infection was 8.68%. The percentage of concordance was 22.4% (13 couples). A presence of tubal occlusion was only associated with infected-discordant women [RR = 3.46, 95% CI (1.54-7.74), p < .003]. Seminal values were not associated with discordant men. The concordant couples showed association with the infection and tubal occlusion [RR = 3.19, 95% CI (1.09-9.34), p < .05], and oligozoospermia [RR = 12.17, 95% CI (4.29-34.54), p < .001], hypospermia [RR = 14.13, 95% CI (4.78-41.84), p < .001]. An alteration in semen quality was shown particularly in men whose sexual partners show a tubal pathology. This could occur due to a C. trachomatis infection in the testis, which underlines the need to carry out effective and efficient strategies to identify and treat all sexual partners exposed to C. trachomatis.

Endometriosis III and IV as a risk factor for tubal obstruction in infertile women.

OBJECTIVE: A previous study carried out among infertile women with tubal obstruction identified a relative risk of 2.5 for Chlamydia trachomatis seropositivity. However, endometriosis may also be associated with increased risk. This study aimed to evaluate the risk of tubal obstruction associated with endometriosis III/IV among women submitted to assisted reproductive procedures. METHODS: A case-control study was performed among 144 women with and without tubal obstruction. We calculated the odds ratio with 95% CI regarding the association of endometriosis III/IV and tubal obstruction. Calculations were performed using the SPSS v.17.0 package. RESULTS: The mean age was 33.7 years (4.76 SD), and the mean infertility duration time was 66.7 months (120.6 SD). The total prevalence of endometriosis was 20/144 (13%). Among 144 women, the risk group with tubal obstruction and endometriosis III/IV comprised 7out of 20 (35%), compared with the group without such risk, that comprised 22 out of 124 (17%). The X2 test was 3.19 with a p-value of 0.07. The odds ratio (OR) was 2.5 (95% CI: 0.647-9.639). CONCLUSION: Although the OR was 2.5, there was no significant difference between the groups with and without endometriosis III/IV. Further studies are needed to increase the sample size.

Patrón menstrual y reserva ovárica en pacientes con salpingectomía y oclusión tubárica para esterilización definitiva / Menstrual pattern and ovarian reserve in patients undergoing to salpingectomy and tubal occlusion for definitive sterilization

Resumen Objetivo: Evaluar el patrón menstrual y la reserva ovárica mediante la determinación de FSH y conteo de folículos antrales en pacientes con salpingectomía y oclusión tubárica bilateral como métodos de esterilización definitiva. Material y métodos: Estudio prospectivo, longitudinal, comparativo, experimental, con asignación al azar, ciego simple, al que se incluyeron pacientes con deseos de esterilización definitiva como método anticonceptivo. Las pacientes se asignaron al azar a dos grupos, el primero con oclusión tubárica bilateral y el segundo con salpingectomía. A los seis meses posprocedimiento se evaluaron en forma ciega el patrón menstrual y la determinación sérica de hormona folículo estimulante (FSH) y el recuento de folículos antrales por ultrasonido transvaginal como marcadores de reserva ovárica. El análisis estadístico se llevó a cabo con t de Student para muestras independientes (comparación entre los grupos) y dependientes (comparación intragrupo) para comparación de medias y la prueba x2 para comparación de proporciones. Resultados: Se estudiaron 60 pacientes, 31 con oclusión tubárica bilateral y 29 con salpingectomía. Se registraron aumentos significativos en los días de sangrado menstrual con respecto a la basal después de la oclusión tubaria bilateral (p = .002) y salpingectomía (p = .008). No hubo diferencias entre oclusión tubárica bilateral y salpingectomía con respecto al tiempo quirúrgico para llevar a cabo la técnica de esterilización (p = .83), duración del ciclo menstrual (p = .35), duración de los días de sangrado menstrual (p = .40). Tampoco resultaron diferencias en las concentraciones séricas de FSH (p = 0.75) ni en el recuento de folículos antrales (p = .44) entre los grupos. Conclusiones: El patrón menstrual y la reserva ovárica son muy similares en pacientes con oclusión tubárica bilateral o salpingectomía. Ambas técnicas incrementan la duración del sangrado menstrual posterior al procedimiento. La salpingectomía implica un aumento ligero en el tiempo quirúrgico, sin diferencias en la frecuencia de complicaciones.

Abstract Objective: To evaluate the menstrual pattern and ovarian reserve in patients undergoing salpingectomy and bilateral tubal occlusion as definitive sterilization methods. Material and methods: A prospective, longitudinal, comparative, experimental, randomized, single blind study was carried out in patients with a desire for definitive sterilization as a contraceptive method. Patients were randomly assigned to perform bilateral tubal occlusion or salpingectomy. Six months after the procedure in each patient, the menstrual pattern and the serum determination of follicle stimulating hormone (FSH) and the antral follicle count were evaluated by transvaginal ultrasound as markers of ovarian reserve. The statistical analysis was carried out using the student's t-test for independent samples (comparison between groups) and dependent samples (intra-group comparison) for comparison of means and the x2 test for comparison of proportions. Results: Sixty patients were studied, 31 with bilateral tubal occlusion and 29 with salpingectomy. Significant increases were observed in the days of menstrual bleeding with respect to the baseline after bilateral tubal occlusion (p = .002) and salpingectomy (p = .008). No differences were observed between bilateral tubal occlusion and salpingectomy with respect to the surgical time to carry out the sterilization technique (p = .83), menstrual cycle duration (p = .35), duration of the days of menstrual bleeding (p = .40). No differences were observed in the serum levels of FSH (p = .75) nor in the antral follicle count (p = .44) between the groups. Conclusions: The menstrual pattern and the ovarian reserve are very similar in patients who undergo bilateral tubal occlusion and salpingectomy, although the two techniques increase the duration of menstrual bleeding after the procedure.

Tubo-ovarian abscess after tubal ligation.

Tubo-ovarian abscess usually results from ascending infection of the lower genital tract. In a few cases it can occur as a result of direct contamination at the time of tubal sterilization. We describe a case that presented seven years after post partum tubal sterilization, showing both acute and chronic components.

PIP: This paper presents the case of a 32-year-old woman who developed a tubo-ovarian abscess 7 years following tubal ligation via minilaparotomy. Symptoms experienced included pain, which was exacerbated by walking, and mild deep dyspareunia. Abdominal and pelvic examinations revealed pain in the left iliac fossa, cervical excitation tenderness, and an ill-defined left adnexal mass. Sonographic evaluation of the pelvis showed an irregularly shaped, cystic mass (8.0 x 4.5 x 5.3 cm) with thickened internal septations and solid parts. A left tubo-ovarian multilobulated complex mass adherent to the omentum and the pelvic side was found upon laparotomy. There was pus in the Pouch of Douglas, and the uterus was 10 weeks in size with symmetrical enlargement. The previously ligated right fallopian tube and the ovary were unremarkable. Management includes left adnexectomy, omental biopsy, and 5-day course of antibiotics against Staphylococcus aureus, which was cultured from the purulent material in the Pouch of Douglas. Tubo-ovarian abscess should be considered in diagnosing patients presenting symptoms of pelvic inflammatory disease.

[Closure of the skin with cyanoacrylate in surgical wounds after tubal sterilization]. / Cierre de la piel con cianocrilato en las heridas quirúrgicas después de la obstrucción tubaria bilateral.

Close of skin with cyanocrilate in surgical wounds after tubary sterilization. The objective was to determine the use of cyanocrillate in surgical wounds coalescence, to decrease the time employed when closing the skin, as well as to aid the healing process. This is an observation, prospective, length, comparison, study. Since March, 1995, the Gyneceum-Obstetrics "Luis Castelazo Ayala" Hospital has carried out this research, forming two groups as follows. Group A: Tubary sterilization (OBT) was practiced to 36 patients applying a superficial coat of cyanocrilate. Group B included 31 patients whose skin was sutured with catgut 00. In Group A. the average time for skin closure is 14.5 seconds, in wounds with a length of 2 to 6 cm. In Group B the average time is 3.9 minutes, in wounds with a length of 1 to 4 cm. 4 cases of group A reported pain for the first 12 hours (11.1%), pruritus in wound in 3 cases (8.3%), partial dehiscence of wound, 1 case (2.7%). While in Group B the result are: Pain in 10 cases (32.2%), pruritus in 3 cases (9.6%), partial dehiscence of wound in 3 cases (9.6%), 1 case with poor edges coaptation (3.2%), and reaction to suture in 2 cases (6.4%). Not even an infection condition occurred. Cyanocrilate used in selected cases is an inexpensive, fast, easy to use efficient method, with little morbidity and likely to improve the aesthetic of surgical scar.

PIP: 100 women undergoing bilateral tubal sterilization at a hospital in Mexico City between March and September 1995 participated in a prospective study of the use of the contact adhesive cyanoacrylate for closure of the surgical wound. Cyanoacrylate was used for the patients in group A, while in group B the skin was sutured with catgut 00. The remainder of the procedure was similar in both groups. The 36 patients in group A and 31 in group B who attended follow-ups at 12 hours, 7 days, and 40 days were included in the study. Patients in group A ranged in age from 20 to 36 and averaged 31.7 years, while those group B ranged from 18 to 35 and averaged 27.5 years. Group A patients had 2.8 and group B 3.1 children on average. The wounds in group A ranged from 2 to 6 cm and averaged 3.1 cm, while those in group B ranged from 1 to 4 cm and averaged 2.5 cm in length. The time for wound closure ranged from 4 to 30 seconds and averaged 14.5 seconds in group A, and from 1 to 7 minutes with an average of 3.9 minutes in group B. 4 patients in group A had pain (11.1%), 3 had pruritus (8.3%), and 1 each had (2.7%) poorly joined borders, partial dehiscence of the wound, and bleeding. 10 patients in group B had pain (32.2%), 3 each (9.6%) had pruritus and partial dehiscence of the wound, 1 had poorly joined borders (3.2%), and 2 had reactions at the site of the sutures (6.4%). It was concluded that, in appropriately selected cases, cyanoacrylate is inexpensive, rapid, easy to use, and efficient, with few side effects.

Multidisciplinary experience in the selection of patients for tubal sterilization.

Results of the use of a special protocol for evaluation of patients requiring tubal ligation is presented after applied by a multidisciplinary group. The authors conclude that the use of defined parameters of age, parity, marital union duration, number of children alive and the presence of maternal clinical pathology are useful to identify patients with smaller chances of regret after surgery.

PIP: 27% of reproductive-age women in Brazil have chosen surgical sterilization as their contraceptive method. Most of these women who have undergone tubal sterilization opted for cesarean surgery. However, given the young ages of many of these women, many regret having been sterilized. This paper summarizes the experience of a multidisciplinary group in evaluating women who apply for surgical sterilization at the Department of Tocogynecology, Faculdade de Ciencas Medicas, Universidade Estadual de Campinas in Sao Paulo. Detailed descriptions are presented of the medical and social characteristics of cases seen between June 1988 and July 1989. The authors conclude that the use of the defined parameters of age, parity, marital union duration, number of living children, and the presence of maternal clinical pathology are useful in identifying the patients who are least likely to regret undergoing surgical sterilization.

[Bilateral tubal occlusion by postpartum mini-laparotomy under local anesthesia and sedation]. / Oclusión tubaria bilateral por minilaparotomía post parto con sedación y anestesia local.

The first 1000 cases of tubal sterilization post-delivery by minilaparotomy with sedation and local anesthetic, were reviewed; these procedures were realized at the Hospital of Zona Francisco del Paso y Troncoso of the IMSS, in México City, during the period comprehended between December 1990 and October 1991. The greatest group of cases by age corresponded to the period between 20 to 29 years in 52.3%. 65% of the women had 3 or 4 children alive. The range of the diastolic blood pressure was between 70-80 mmHg in 66.3%. 19.7% with a value of hemoglobin less than 10 g. 2.3% of the patients with 100-120 kgs. of weight. The contraceptive method used previously with greatest frequency was the DIU in 40.6%. In all of the cases the indication was satisfied parenthood. In 100% of the cases the same drug was used for sedation, diazepam (oral) and chlorhydrate of nalbulfine, with simple lidocaine as a local anesthetic. Likewise in all the cases the Pomeroy technique was performed. The time between the childbirth and the surgery was less than 12 hours in 92.9% of the cases. And the time between the surgery and the recuperation reset was of 12-34 hours in 96%. In 0.8% of the cases the transoperatory complication of the surgery was the bleeding as a result of tearing of the mesosalpinx. The postoperatory complications after one week were the formation of hematoma and/or abscess at the site of the incision representing 0.5% of the cases. All these procedures are realized at a unit that was created especially for this kind of surgery and treatment.

PIP: The first 1000 postpartum tubal occlusions by minilaparotomy under sedation and local anesthesia performed at a Mexican Institute of Social Security hospital in Mexico City were retrospectively reviewed. The operations took place between December 1990 and October 1991. The youngest patient was 17 and five patients were under 20. 52.3% were aged 20-29, 31.9% were aged 30-34, and 13.8% were aged 35-40. 65% of the women had three or four live births and 16.8% had two. The diastolic blood pressure was between 81 and 90 for 12.1%, between 91 and 100 for 8.9%, and between 101 and 120 for 3.7%. 19.7% had hemoglobin levels below 10 g. 37 women with hemoglobin levels between 4 and 8 g were sterilized; all received transfusions before discharge. 66.7% of the women weighed between 50 and 70 kg, but 2.3% weighed 100-120 kg. 40.6% used IUDs, 16.8% oral contraceptives, and 14.2% injectable methods. 24.8% had never used a contraceptive method. The Pomeroy technique was used in all cases. All patients were given Lidocaine. The operation was performed within 12 hours of delivery in 92.8% of cases. 96.3% of the women were discharged within 24 hours. Bleeding, resulting from tearing of the mesosalpinx, occurred in 0.8% of cases. A hematoma or abscess at the site of the incision was observed in 0.5% at one week follow-up. The data indicate that bilateral tubal occlusion by postpartum minilaparotomy under local anesthesia and sedation, rather than general anesthesia, is a rapid and safe procedure, even for obese and hypertensive women.

[Non-surgical female sterilization using quinacrine: efficacy of two insertions of quinacrine pellets]. / Stérilisation féminine, non chirurgicale avec l'emploi de quinacrine: efficacité de deux insertions de pellets de quinacrine.

In a group of 159 women at Santiago du Chili, fertility control by means of chemical occlusion of the utero-tubular junction was assessed. Two transcervical intra-uterine insertions of 216 mg of quinacrine, carried out at an interval of one month and associated with 50 mg of intra-uterine diclofenac and 150 mg of intra-muscular diclofenac resulted in a pregnancy rate after 12 months of 2.1 per 100 women and a Pearl index of 1.63 at 27 months after the sterilization process. The complications and adverse events appear to be similar to those which occur during insertion of an IUD and were minor and transient, disappearing within a few hours or at most 2 days after the procedure.

PIP: A group of 147 women participated in a study of outpatient tubal occlusion with quinacrine pellets at a hospital in Santiago, Chile. Six pellets, each containing 36 mg of quinacrine, were inserted transcervically into the uterus by means of a plastic tube in a procedure resembling IUD insertion. The women also received 50 mg of intrauterine diclofenac and 150 mg of intramuscular diclofenac. The initial procedure was carried out within the first postmenstrual cycle week, and was repeated at the same cycle phase on month later. No procedures were done within 42 postpartum days. The study women were 34.9 years old an average and had an average of 4.9 living children. Of the 159 patients who completed the two scheduled insertions, 140 were followed for 27 months and the other 19 were lost to follow-up. Three women became pregnant within two years. The Pearl index was 1.63 for 2198 woman-months. The percentages of pregnancies were 0.62 for the first year and 1.25 for the second year. None of the pregnancies was ectopic. One pregnancy was terminated by a medical abortion, and the patient was surgically sterilized. No abnormality was observed during laparotomy. The other two pregnancies terminated in normal delivery of healthy infants. Twenty women had adverse reactions during the 24 months of observation, but most were minor. No hospitalization or additional surgical procedures were required. Three women had post-insertion metrorrhagia, which lasted a maximum of two days.

Abdominoplasty combined with other intraabdominal procedures.

One hundred three patients underwent abdominoplasty combined with other intraabdominal procedures including 67 tubal ligations, 34 total abdominal hysterectomies and 2 cholecystectomies, from January 1983 to July 1991. The patients were divided into two groups, those undergoing the standard or total abdominoplasty and those undergoing limited abdominoplasty with or without liposuction in delimited areas. In this series of 103 patients, we found only two minor complications and only three patients were transfused with autologous units of blood. When performed by well-schooled surgical teams, abdominoplasty may be combined with intraabdominal procedures with gratifying results.

PIP: Between January 1983 and July 1991, well trained surgical teams performed either standard abdominoplasty or miniabdominoplasty on 103 patients who also underwent tubal ligation, total abdominal hysterectomy, or cholecystectomy to determine whether surgeons can effectively combine abdominoplasty with other intraabdominal procedures. Prescribed preoperative procedures included respiratory exercises. Physicians advised patients to stop smoking 2 weeks before surgery. Physicians also instructed them not to take any aspirin or other drugs with anticoagulant effects 2 weeks before surgery. Tubal ligation patients who also underwent standard abdominoplasty were in the operating room for 3 hours and for 2 hours if they underwent miniabdominoplasty. Total abdominal hysterectomy patients were in the operating room for either 3-4 hours (standard abdominoplasty) or 2.5-3 hours (miniabdominoplasty). Surgeons performed cholecystectomy in those patients who only underwent standard abdominoplasty. They were in the operating room for 4-5 hours. The combination of intraabdominal procedure and standard abdominoplasty increased the time in the operating room by 40-90 minutes. Number of days in the hospital for standard abdominoplasty patients included 2-3 for tubal ligation, 5 for total abdominal hysterectomy, an 5-7 for cholecystectomy. Miniabdominoplasty patients were in the hospital 1-2 days for tubal ligation and 5 days for total abdominal hysterectomy. Only 2 minor complications occurred: a seroma and a minor skin slough. 3 patients required transfusion of autologous units of blood and non of them lost more than 500 ml of blood. The physicians encouraged all patients to become ambulatory soon after the operation and to wear elastic stockings to prevent thromboembolic events. As a result, none of the patients suffered a pulmonary embolism. In conclusion, good surgical teams can safely and effectively combine abdominoplasty with intraabdominal procedures.

IPPF Brazil program confronts sterilization accusations.

PIP: Even though Brazil's BEMFAM program stopped providing sterilization services over a year ago, many sources hostile to BEMFAM in the Brazilian government are still accusing it of misconduct. BEMFAM is sponsored by the International Federation of PLANNED Parenthood and was investigated and cleared of any wrong doing by the Brazilian government. In Brazil it is against the law to perform sterilization for the purposes of birth control, yet it is estimated that there are between 6-20 million such operations each year. Over 65% of the births in Brazil are by Caesarian section and it is common for women to ask their doctors to perform a tubal ligation at the same time. Abortion is illegal in Brazil, but there are an estimated 1.4-2.4 million abortions each year. 56% of Brazilian women use contraceptives, with 90% using either the pill or illegal sterilization. 90% of those who use the pill obtain it over the counter at pharmacies with inadequate knowledge on how to use it. 80% of the people receive their health care from the Brazilian government.^ieng

Researchers assess data on long-term safety of non-surgical sterilization method.

PIP: Concerned over a possible link to cancer, researchers from Family Health International (FHI) have begun investigating the long-term safety of the chemical used for non-surgical sterilization, a study being carried out among Chilean women. In the late 1960s, the chemical quinacrine hydrochloride was found to be an effective means of occluding the Fallopian tubes for the purpose of contraceptive sterilization. This is done through the transcervical insertion of 2 quinacrine pellets, which inserted 1 month apart. The use of quinacrine has several advantages over surgical sterilization: no incision, general anesthesia, or hospitalization is required; it can be performed by paramedics on an outpatient basis; and it effectively prevents pregnancy. Quinacrine, however, also has disadvantages, including the fact that it requires 2 applications, that the sterilization cannot be reversed, and that it increases the risk of ectopic pregnancy. Additionally, the long-term safety of this contraceptive method is not yet known. From the late 1970s to 1986, 572 women in Chile took part in clinical trials of quinacrine, tests which were supported by FHI. Continuing to monitor the health of these women, FHI recently discovered 8 cases of malignancy in 6 different anatomical sites. Although it is not known whether this figures reflect a significant difference in the incidence of malignancies between the trial group and the general population, the finding has prompted the organization to undertake a study of a possible association between the use of quinacrine pellets and malignancy.^ieng

[Family planning among lower status women in Rio de Janeiro city]. / Planejamento familiar em mulheres de baixa renda no Municipio do Rio de Janeiro.

PIP: The National School of Public Health aided by WHO conducted a survey between 1984 and 1985 in 7 communities of Rio de Janeiro, Brazil, enlisting 1900 women aged 15-49 from 2019 households selected. 1783 were interviewed, yielding a response rate of 92%. 538 (30%) women were single, 7.2% of who had no sexual experience. 4.5% of the sample were widowed, divorced, or separated. Their familiarity with contraceptives was as follows: oral contraceptives, (OCs) 99.7%; female sterilization and the condom, 90%; coitus interruptus and vasectomy; 33%; the diaphragm, 27%; and natural methods; 22%. 83% of the women used OCs; less than 20% used the condom, coitus interruptus, or spermicides; and 5% had used the IUD. 8% of those 40 decided on tubal sterilization. 67% of the women in sexual unions used contraceptives vs. 35% of single women with sexual activity. Nonuse increased after age 35, while more than 50% of women 20 did not use contraceptives. Half of the sterilized women underwent the procedure before age 30 when they had 4 children. 66% of ligations were done during birth, and accompanied 63% Cesarean section. Only 28 of sterilizations were done by laparoscopy on another occasion. Misinformation about sterilization was rife, as 15% of sterilized women states that they wanted to bear a child in the future, and 11% thought that they could get pregnant. 42% of women aged 35 and over were sterilized by laparoscopy. In hospitals and clinics the average sterilized woman was 29.4 years old and had 3.5 children. Contraceptive prevalence was higher than the national average, it was comparable to the level in countries that have traditionally low fertility. The fact that OCs, the pill, and tubal ligation made up the predominant pattern of contraceptive use is the result of the inability of the health care system to provide an integrated family planning program with education about and provision of contraceptives.^ieng

[Morbidity from bilateral tubal ligation, via laparoscopy]. / Morbilidad de la obstrucción tubaria bilateral, vía laparoscopia.

From January 1, 1987 January 30, 1990, 374 laparoscopic sterilizations using silastic rings (Falope), were carried out. Morbidity and main risk factors, were analyzed. More frequent surgical complications were: mesosalpinx rupture, and fallopian tube rupture in 22 cases (5.8%); abdominal wall emphysema, three cases (0.8%), uterine perforation, two cases (0.5%); other pelvic structures lesions, three cases (0.8%). Morbidity risk factors were: previous abdominal surgery, obesity, salpingitis, use of an uterine mobilizer in a puerperal uterus, and practice of tubal occlusion during the luteal phase of cycle, due to possibility of luteal phase pregnancy; therefore, if a risk factor is present, it is advisable to use other contraceptive technique.

PIP: Between January 1, 1987-January 30, 1990, 374 laparoscopic sterilizations using silastic rings (Falope) were undertaken. Morbidity and major risk factors were analyzed. The most frequent surgical complications were: mesosalpinx rupture and fallopian tube rupture in 22 cases (5.8%); abdominal wall emphysema in 3 cases (0.8%); uterine perforation in 2 cases (0.5%); other pelvic structure lesions in 3 cases (0.8%). Morbidity risk factors were: previous abdominal surgery, obesity, salpingitis, use of a uterine mobilizer in a puerperal uterus, and the practice of tubal occlusion during the luteal hase of the cycle due to the possibility of a luteal phase pregnancy. Therefore, if a risk factor is present, it is advisable to use another contraceptive method. (author's modified)

Epidemic of caesarean sections in Brazil.

Brazil has one of the highest rates of caesarean section in the world. Patterns of caesarean sections were studied in a cohort of 5960 mothers followed from 1982 to 1986 in southern Brazil. Overall, 27.9% were delivered by caesarean section in 1982, this proportion being 30% for nulliparae, 80% for second deliveries when the first was by caesarean, and over 99% for third births when the first two were by caesarean. Socioeconomic status and requests for sterilisation by tubal ligation were important underlying factors. 9.4% of the women were sterilised during a caesarean section (3.7% in the lowest income group and 20.2% in the highest). 31% of women who had had their first child by a caesarean section and who were having a second operative delivery were sterilised. The high rates of caesarean sections and accompanying sterilisations reflect the lack of appropriate reproductive and contraceptive policies in the country.

[Voluntary sterilization]. / La esterilizacion voluntaria.

PIP: Voluntary sterilization is the chosen family planning method of more couples worldwide than any other, evidence of its acceptability and lack of serious shortcomings. This work offers observations on training, counseling, supervision, cost-effectiveness, and acceptability of voluntary sterilization programs, and presents some results of Profamilia's program. Training of qualified medical personnel in the available techniques is a relatively simple. Profamilia has trained almost 1000 medical professionals, nearly half of whom were from other countries, but a legal technicality has forced Profamilia to curtail training of foreign professionals. It is much more difficult to train personnel to identify and inform potential clients about sterilization, promote the procedure, and provide follow-up, yet these program activities are crucial to a successful sterilization program. Counseling of couples is necessary and should include discussion of the greater convenience of vasectomy compared to tubal ligation. Sterilization should be presented as a permanent method. This permanence, often viewed as a disadvantage, has a positive side in freeing couples of the need for further consideration of family size or contraception and in protecting them against family and social pressures to have more children. Raising marriage age or family size requirements in the hope of avoiding regret does not appear justified. Assuring that sterilization is truly voluntary is a preoccupation of donors, but has not been a problem in Profamilia programs. All clients are required to make some payment and to sign a detailed consent form. Profamilia has been persuaded to discourage mental defectives from undergoing sterilization because of possible legal problems. Periodic, unannounced visits to clinics are recommended for quality control and supervision. Profamilia employs salaried medical personnel for sterilization when careful supervision is available to ensure that they do not unjustifiably reject applicants, and pays on a per-case basis otherwise. It is estimated that each Profamilia sterilization provides 12.5 couple-years of protection. Each sterilization costs US $ 33.20 on average, 60% of it for personnel costs. Profamilia offer highly subsidized services for its lower middle class clients and almost free services for its poorest 40% of clients. The financial strain is considerable for Profamilia, which carries out some 70,000 sterilizations each year at a cost of US $ 2.25 million, only 1/7 of it directly paid for by clients. Since 1973, Profamilia has performed over 700,000 tubal ligations. There have been 19 deaths, 9 attributed to surgical and 5 to anesthetic problems. There are minor complications in about 1% of cases. 26,401 vasectomies were performed through 1990, with 2 cases requiring hospitalization.^ieng

Menstrual patterns and progesterone circulating levels following different procedures of tubal occlusion.

This study was undertaken to assess the effects of different tubal occlusion procedures on ovarian function. Three groups of subjects randomized to tubal occlusion by laparoscopy and Yoon ring (24 subjects), minilaparotomy and Yoon ring (19 subjects) and minilaparotomy and Pomeroy (22 subjects), and one separate control group of 26 healthy subjects not using any form of contraception were studied in a prospective design. The characteristics of the menstrual patterns were studied for one year after sterilization. Determination of the circulating progesterone levels were made on days 15, 20 and 25 of menstrual cycles initiated 1, 3, 6 and 12 months following the tubal ligation. In the analysis of the bleeding pattern there was a statistically significant difference in the mean segment length and in the longest bleeding-free interval in the subjects who had been sterilized by minilaparotomy with Yoon ring, when compared to the other two study groups and to the control group. However, the magnitude of this difference in number of days was not considered clinically significant. There was no statistically significant difference in the percentage of ovulatory cycles within the study and the control groups, or when the results of the study groups were compared with each other or to the control group.

PIP: This study was undertake to assess the effects of different tubal occlusion procedures on ovarian function. 3 groups of subjects randomized to tubal occlusion by laparoscopy and Yoon ring (24 subjects), minilaparotomy and Yoon ring (19 subjects) and minilaparotomy and Pomeroy (22 subjects), and 1 separate control group of 26 healthy subjects not using any form of contraception were studied in a prospective design. The characteristics of the menstrual patterns were studied for 1 year after sterilization. Determination of the circulating progesterone levels were made on days 15, 20, and 25 of menstrual cycles initiated 1,3,6 and 12 months following the tubal ligation. In the analysis of the bleeding pattern there was a statistically significant difference in the mean segment length and in the longest bleeding-free interval in the subjects who had been sterilized by minilaparotomy with Yoon ring, when compared to the other 2 study groups and to the control group. However, the magnitude of this difference in number of days was not considered clinically significant. There was no statistically significant difference in the % of ovulatory cycles within the study and the control groups, or when the results of the study groups were compared with each other or to the control group. (Author's).

Sterilization regret among Puerto Rican women.

This study examined sterilization regret among Puerto Rican women with contraceptive tubal sterilizations (TS) using retrospective data from a population-based survey of women aged 15 to 49 years. Twenty-one percent of the 846 respondents expressed some regret, with 11% stating definite dissatisfaction with the decision. Factors associated with regret were young age at TS, absence of daughters, someone else making the decision to be sterilized, medical indications for TS, sterilization failure, and living with a new marital partner. There were no significant effects associated with the timing of sterilization, whether interval or postpartum, or with the type of last delivery. Other factors not independently associated with regret included years since TS, parity, education, and age at follow-up.

PIP: Reasons for sterilization regret in Puerto Rican women were examined from interview data from the 1982 Puerto Rico Fertility and Family Planning Assessment. 846 of the 3175 women surveyed had contraceptive tubal sterilization, i.e., medical sterilizations, vasectomies and hysterectomies were excluded. Sterilization took place between 1954 and 1982, in women aged 15-49 years old at the time of the interviews. 42% of the subjects lived in rural areas. Regret was expressed on the questionnaire as definitely yes, maybe yes, maybe no, or definitely no. 21% of these women expressed some regret, and 11% felt definite regret for having been sterilized. The most common reasons for regret were desire for more children then, or change of heart later, and not being consulted about the operation. Factors associated with regret were age under 25 at operation, having no daughters, husband or physician having decided on sterilization, medical indications for sterilization, sterilization failure and living with a new partner. Factors not significantly related to regret included timing of sterilization with respect to childbirth, years since sterilization, parity, education and age at survey.

Four-year follow-up of electrocoagulation and tubal ring sterilizations in Costa Rica.

An earlier analysis of 299 laparoscopic sterilizations comparing electrocoagulation and tubal ring occlusion techniques found no significant differences in rates of surgical complications. The risk of potentially serious complications, such as bowel/bladder burns, was considered higher with electrocoagulation be the preferred technique. Examination of the same women through 48 months poststerilization between the two techniques with respect to the incidence of gynecologic surgery performed subsequent to sterilization. Gynecologic abnormalities were similar for women in both groups. The rate of pregnancy was higher for tubal rings than for electrocoagulation (2.1 compared to 0.7 at 48 months) but this difference was not statistically significant.

PIP: An earlier analysis of 299 laparoscopic sterilizations comparing electrocoagulation and tubal ring occlusion techniques found no significant differences in rates of surgical complications. The risk of potentially serious complications, such as bowel/bladder burns, was considered higher with electrocoagulation suggesting that tubal rings might be the preferred technique. Examination of the same women 48 months posterilization showed no signficant difference between the 2 techniques with respect to the incidence of gynecologic surgery performed subsequent to sterilization. Gynecologic abnormalities were similar for women in both groups. The rate of pregnancy was higher for tubal rings than for electrocoagulaton (2.1 compared to 0.7 at 48 months) but this difference was not statistically significant. 151 women (50.5%) underwent sterilization by electrocoagulation; 148 women (49.5%) were sterilized using the tubal ring occlusion technique. All procedures were single incision laparoscopies.

[Family planning. Current levels and trends in contraceptive use]. / Planificacion familiar. Niveles y tendencias recientes del uso de anticonceptivos.

PIP: The general law on population in Mexico has contributed to a noticeable increase in the use of contraceptives. In 1973 only 12% or 900,000 women practiced modern contraception, which increased to 30% by 1976 (with the inclusion of the rhythm and coitus interruptus methods), 47.7% by 1982, and 53% or 7 million couples by 1987. Business provided 70% of contraceptives in 1970, while by 1982 53.4% and by 1987 61.8% was provided by government. The most utilized method until 1982 was female sterilization, 35.5% (18.8% or 2.5 million had tubal ligation by 1987), IUDs 19.8%, pills 18.3%, the rhythm and coitus interruptus, 15.1%, respectively. 1/3 of the 35-39 and 40-44 age groups had tubal ligation and as did 1/4 of the 30-34 age group, as well as 12.6% and 3.3% of the 25-29 and 20-24 age groups, respectively. The surgical method was used by 46.4% of uneducated women and 23.9% with secondary or higher education. This seems to contradict the hypothesis that education is the motivating factor of in the use of contraception, although some kind of contraceptive was used by 70% of women with high school education vs. 23.5% of women with no education. In rural areas inhabited by less than 2500 people, 37.6% of women practiced contraception compared with 59% and 66% in the 3 largest metropolitan areas. The increase of contraceptive use was less in recent years than in the period 1976-1982, but about 20% of women do not want more children. The various methods of regulating fertility need to be evaluated because of increasing integration of segments of population previously excluded by geographical, cultural, and social barriers.^ieng