The cervical cap: effectiveness, safety, and acceptability as a barrier contraceptive.

PIP: The experiences of 217 volunteers fitted with the cervical cap were analyzed to asses the cap's effectiveness. The cervical cap's a contraceptive barrier device used widely in Europe and currently under consideration by the Food and Drug Administration for release in the US. In 24 months of use, 43 pregnancies were reported among 39 women (4 became pregnant twice with the cap). The Pearl Index was 22.7 pregnancies/100 woman-years of use. Neither the characteristics of participants nor the characteristics of cap use affected the pregnancy rate significantly. However, the pregnancy rate was higher in participants reporting an average frequency of intercourse of 20 or more times/month and in those who observed cap displacement sometime during intercourse. Medical problems associated with cap use were minimal. Increased vaginal odor was the side effect reported most frequently. The majority of participants deemed the cap a positive contraceptive; 83% stated they would recommend it to friends.^ieng

Recognition and treatment of premenstrual syndrome.

Premenstrual syndrome (PMS) is the title applied to a broad range of physical and psychological symptoms that occur cyclically, usually seven to 14 days prior to the onset of a woman's menstruation, and disappear during menstruation. Although the symptoms of premenstrual syndrome were described more than 50 years ago, recognition of PMS by the medical establishment as a discrete condition, which requires attention and treatment, is a fairly recent development. It is estimated that 30 percent of women experience PMS in a debilitating form at some point in their lifetimes from menarche to menopause. The symptomatology of PMS is varied; it includes such psychological symptoms as irritability, depression, oversensitivity, mood swings and anxiety, in addition to such physical symptoms as water retention, breast tenderness, weight gain and migraines. This broad range of symptoms has increased the difficulty of establishing an etiology for the syndrome, and it is now suggested that there may be several processes at work, each responsible for a different aspect of PMS. Care of the PMS patient by nurse practitioners initially requires acknowledgment of the legitimacy of her condition. A detailed physical examination should be accompanied by careful interviewing to elicit the most complete picture of the patient's experience with PMS. Treatment, which can involve dietary changes, hormone or antigonadotropin administration, must be individualized according to a patient's initial symptomatology and subsequent response. At present, research is in progress which will enhance our understanding and ability to deal with PMS.

Preabortion cervical dilatation with a low-dose prostaglandin suppository. A comparison of two analogs.

Vaginal administration of PGE2 and PGF2 alpha suppositories resulted in cervical changes that facilitated suction curettage termination of 46 first-trimester pregnancies. When 30 mg of 9-deoxo-16,16-dimethyl-9 methylene PGE2 was compared with 0.5 mg of 15(S)-methyl PGF2 alpha suppositories, the cervix-ripening properties of these two agents appeared to be equivalent. Within one to two hours of insertion, a mean dilatation increase of 3.3 and 3.1 mm was achieved for the PGE2 and PGF2 alpha groups, respectively, increasing the ease of suction abortion. Blood loss and gastrointestinal side effects were minimal for both groups. The rapid effectiveness of these suppositories for cervical priming permits a one-day hospital stay for abortion and may minimize long-term sequelae associated with forceful mechanical dilatation of the cervix.

Vasectomy and atherosclerosis in Macaca fascicularis. New findings in a controversial issue.

The influence of vasectomy on diet-induced atherosclerosis was studied in ten Macaca fascicularis monkeys. After a six-month control period the monkeys were divided into two groups and matched for cholesterol levels. Five monkeys were given vasectomies and five sham vasectomies, and all animals were placed on a high-cholesterol, atherogenic diet. The vasectomized monkeys showed a significant increase in sperm antibody formation as compared with the control group. Both groups developed similar high cholesterol levels. After ten months all monkeys were necropsied, and their vascular systems were carefully evaluated to determine the extent of atherosclerosis. There was no difference in the occurrence of atherosclerotic plaques between the study and control groups despite sperm antibody development in the study group. This finding is in contrast to those of previous animal studies in which it was theorized that vasectomy aggravated the development of atherosclerosis. This study, however, confirms the results of several human studies that have failed to find any increase in cardiovascular disease among men who have undergone vasectomy.

Reliability of antenatal testing: estriol levels versus nonstress testing.

During the third trimester of pregnancy, 334 high-risk patients were followed with antenatal fetal heart rate (FHR) evaluation and with serial determinations of unconjugated plasma estriol. The antenatal FHR tests included nonstress testing (NST) and investigation of beat-to-beat variability. Data indicate that the NST was more reliable than estriol analysis in assessing fetal compromise. While predictive values of negative test results did not differ statistically, the NST/beat-to-beat assessment was particularly accurate in identifying fetal jeopardy in more than 45.0% of the fetuses at risk, whereas only 22.8% cases of jeopardy were accurately predicted by abnormal estriol values. An abnormal NST with loss of beat-to-beat FHR variability should therefore take precedence over plasma estriol determinations during antenatal surveillance of high-risk obstetric patients.

133Xenon clearance from amniotic fluid in baboons during administration of oxytocin, prostaglandin F2 alpha and a beta-mimetic agent.

Amniotic fluid clearance of 133xenon was measured in pregnant baboons near term during a control period of spontaneous uterine activity and during induction of contractions with oxytocin or PGF2 alpha and inhibition of activity by a beta-adrenergic agent, berotec. There was no significant change in the clearance of 133xenon from the amniotic fluid during moderate uterine activity induced by oxytocin or PGF2 alpha. The clearance rate decreased five-fold during infusion of berotec, compared with the control infusion periods, simultaneous with a decrease in uterine activity. When the berotec infusion was discontinued, the clearance of 133xenon immediately returned to the previous level, while the return of uterine activity was more gradual.

Cervical priming prior to dilatation and evacuation: a comparison of methods.

Vaginal administration of prostaglandin analogues resulted in cervical changes that facilitated dilatation and evacuation in 80 patients in the late first trimester and the second trimester of pregnancy. When 0.5 mg and 1.0 mg of 15(S)-15-methyl-prostaglandin F2 alpha (15-ME-PGF2 alpha) was compared to 30 and 60 mg of 9-deoxo-16,16-dimethyl-9 methylene prostaglandin E2 (PGE2 analogue), the PGE2 analogue appeared to have more cervical ripening effect than did the 15-ME-PGF2 alpha. Overall, the 30 mg PGE2 vaginal suppository seemed to offer the most optimal combination of effectiveness, sufficient cervical dilatation, and minimal side effects. With the prostaglandins, maximal cervical effect was observed at 4 to 5 hours; this rapid effectiveness allows administration of the prostaglandin to accommodate a 1-day stay for surgical evacuation. The preoperative cervical priming results with the prostaglandins were compared to those obtained with the use of laminaria tents. Although the number of patients who needed further dilatation at the time of operation was less with the laminaria, the incidence of complications and the time for adequate dilatation were higher in that group.

A new iud insertion technique utilizing cervical priming with prostaglandin.

Cervical priming with the aid of a single 15-ME-PGF2a vaginal suppository prior to IUD insertion resulted in cervical changes which facilitated the procedure. A 0.5 mg 15(S)-15-prostaglandin F2a methyl ester vaginal suppository was administered one hour prior to the IUD insertion in all patients studied. The insertion was performed in all patients studied. The insertion was performed from seven to seventeen days following the LMP with the exception of four patients with prolonged amenorrhea. A mean increase in cervical dilatation of 2.14 mm was achieved with minimal side effects. The cervical ripening and dilatation produced by the suppository increased the ease of IUD insertion , and expanded the time frame in which an IUD insertion could be performed. The method was well tolerated by all patients and eliminated the nausea and syncope often associated with IUD insertion.

Meperidine-induced sinusoidal fetal heart rate pattern and reversal with naloxone.

A case of sinusoidal fetal heart rate (FHR) pattern in association with maternal intrapartum administration of meperidine is presented. The sinusoidal pattern was reversed after maternal intrapartum administration of naloxone. The significance of this problem and the management of patients with sinusoidal FHR are discussed. The conclusion is reached that iatrogenic causes may at times precipitate a sinusoidal FHR pattern and conservative management may be appropriate.

Microprocessor-controlled doppler. A new fetal heart rate monitoring technique.

A new Doppler fetal heart rate (FHR) monitoring system using microprocessor-controlled ranged directional Doppler (RDD) was developed. The instrumentation was evaluated for accuracy and reproducibility of results by computer measurement and statistical analysis of the difference between FHR simultaneously obtained from Doppler and from fetal scalp electrocardiography (ECG) in 20 high-risk patients during labor. During 90% to 93.5% of the monitoring time, Doppler-derived FHR approximated ECG-FHR to within 5 beats per minute (BPM). The FHR records from this monitoring system can provide accurate and reliable external FHR information that may approximate the internal ECG-FHR record to such a degree that the practitioner is offered a reliable, noninvasive alternative to internal fetal monitoring.

Automatic detection of fetal movement by Doppler ultrasound during non-stress testing.

A new external fetal monitor, using a defocused, wide-area ultrasound transducer has been devised in order to obtain a more accurate representation of fetal movement during antepartum non-stress testing. The fetal activity Doppler signal is easily distinguished from the fetal heart Doppler and provides an automatic record of fetal movement which is objective and reproducible. In several clinical tests, this new monitor was found to be more sensitive and reliable than either reports of fetal movement from the mother or from a physician palpating the abdomen. This method of automatic detection of fetal activity can improve the accuracy of the non-stress test by providing an additional objective criteria.

A new modality in nonstress testing: evaluation of beat-to-beat fetal heart rate variability.

Fetal monitoring equipment that provided accurate external measurement of the interval between each fetal heartbeat permitted the evaluation of beat-to-beat fetal heart rate (FHR) variability as part of routine nonstress testing. Nonstress tests (NSTs) were performed on 350 high-risk patients over a 12-month period. The beat-to-beat FHR variability and the reactivity of the last NST within 7 days of labor were analyzed in relation to the appearance of fetal distress during labor as indicated by late decelerations. Beat-to-beat FHR variability combined with nonstress testing was more predictive of subsequent fetal distress than nonstress testing alone. In all instances, complete loss of beat-to-beat FHR was followed by fetal distress during labor. Fetal distress was present in only 39% of labors following nonreactive NSTs. The inclusion of beat-to-beat FHR variability in nonstress testing can significantly aid in the detection of fetal compromise.

The inhibitory effect of ethanol on oxytocin-induced labor at term.

Intravenous ethanol infusion significantly reduced oxytocin-induced uterine activity in pregnant patients at term. The dose response to oxytocin was linear when plotted log2 x in all patients studied, and the line was shifted to the right by alcohol, but the slope remained essentially unchanged. These results suggest that alcohol directly inhibits the effect of oxytocin on the myometrium, although the possibility of some central inhibition of oxytocin release cannot be discounted.

A new abortion technique: intravaginal and intramuscular prostaglandin.

The 15-methyl analog of prostaglandin F2 alpha (15-ME-PGF2 alpha), administered in a 3-mg dose via a single vaginal suppository and supplemented at 24 hours by intramuscular injection(s) of 250 micrograms, successfully induced abortion in 80 of 81 patients in the midtrimester of pregnancy. The mean abortion time was 19.6 hours. Two thirds of the patients aborted after treatment with the suppository alone in a mean time of 14.6 hours; the remaining 27 patients required intramuscular injections of 15-ME-PGF2 alpha to effect expulsion of the products of conception. Twenty-six of these 27 patients subsequently aborted in a mean total abortion time of 29.6 hours. Fifty-eight patients aborted within 24 hours of the initial prostaglandin administration, and 78 aborted by 36 hours. Parity and length of gestation did not significantly affect abortion time in this series, although the mean abortion time for parous patients and patients with gestations earlier than 17 weeks tended to be somewhat shorter than that of nulliparous patients and those with more advanced gestations. The placenta was spontaneously expelled in the majority of patients. Abortion was incomplete in 3 patients and required curettage. Uterine activity, as measured via an intraamniotic catheter in 6 patients, developed very gradually with the suppository, peaking at 3 hours after insertion, and was characterized by regular contractions with low intrauterine baseline tonus. The gastrointestinal side effects that occurred in 59% of patients who received the suppository were also most frequently observed at 3 hours after administration. In contrast the gastrointestinal disturbances elicited by intramuscular injections of the analog immediately followed the administration.