Use of hormonal contraception in adolescents: skeletal health issues.

PURPOSE OF REVIEW: To summarize the current literature regarding the effects of hormonal contraceptives on adolescents' bone health. RECENT FINDINGS: Use of progestin-only pills, implant and progestin-releasing intrauterine device is associated with low systemic progestin levels that do not appear to impact ovarian estradiol production or bone mineral density (BMD). In contrast, higher systemic progestin levels associated with the use of depot medroxyprogesterone acetate and combination oral contraceptives suppress ovarian estradiol production and reduce acquisition of BMD in teenagers and young adult women who use injectable and oral contraceptives. Although BMD is a predictor of the risk of fracture in postmenopausal women, the clinical implications of BMD changes in teenagers and young women are unknown. Following the hypoestrogenemia associated with the use of depot medroxyprogesterone acetate or lactation, BMD deficits have been found to completely reverse. Although BMD data following combination oral contraceptive use in adolescents is sparse, observations suggest that rapid and complete reversibility of BMD deficits is likely. SUMMARY: Although more data on skeletal health outcomes following the use of oral and injectable contraceptives would be welcomed, theoretic concerns regarding the impact of depot medroxyprogesterone acetate and combination oral contraceptive use on adolescent and young women should not restrict the initiation or continuation of these important contraceptive methods.

Long-acting contraceptives in adolescents.

PURPOSE OF REVIEW: To help clinicians guide adolescent patients to sound choices regarding long-acting contraceptives. The safety, side effects and non-contraceptive benefits of injectable, implantable and intrauterine contraception are detailed. RECENT FINDINGS: The use of depot medroxyprogesterone acetate contraceptive injections has been associated with declines in teenage pregnancies in the United States. Although the US Food and Drug Administration has placed a black box warning concerning skeletal health and depot medroxyprogesterone acetate, data in adolescents confirm that declines in bone mineral density with depot medroxyprogesterone acetate are fully reversible. Concerns regarding skeletal health should not restrict the initiation or continuation of depot medroxyprogesterone acetate in adolescents. A highly effective, convenient, and easy to insert/remove single rod progestin-only contraceptive implant (Implanon) is now available in the United States. Although not widely used in adolescents, intrauterine devices offer selected adolescents convenient, highly effective, safe birth control. Use of the progestin-releasing intrauterine device (Mirena) is also associated with important non-contraceptive benefits. SUMMARY: The efficacy and convenience associated with long-acting contraceptives make them indispensable for adolescent patients. This review will help clinicians guide teenage patients towards sound contraceptive choices and the successful long-term use of injectable, implantable and intrauterine methods of birth control.

Assessing perinatal hepatitis B screening and neonatal prophylaxis in a large, multiethnic county.

OBJECTIVE: To assess the completeness of maternal screening and appropriateness of newborn prophylaxis for hepatitis B virus (HBV) in 2001 in Florida's largest county. STUDY DESIGN: A retrospective cohort study sampled 1% of deliveries at all hospitals in Miami-Dade County that had delivery suites. Abstractors reviewed mothers' and newborns' charts before discharge to determine whether newborns received appropriate HBV prophylaxis based on mothers' hepatitis B virus surface antigen (HBsAg) status at 12 hours postpartum. At each hospital, deliveries were sampled sequentially until the target number was reached. Sampling was donefor March-August 2001. RESULTS: Among 339 deliveries at 14 hospitals, the mother's HBsAg status was known within 12 hours of delivery for 286, or 84.4% (95% CI 80.1-88.1%). Of the 53 infants whose mothers' HBsAg status was unknown, 15 (28.3%) were vaccinated within 12 hours of delivery; both infants whose mothers were HBsAg positive received vaccine and immune globulin within 12 hours delivery. CONCLUSION: While HBsAg screening of pregnant women is widespread in Miami-Dade County, the information is not consistent used to protect infants who mothers' HBsAg status unknown.

Outcome of pregnancies among Hispanics: revisiting the epidemiologic paradox.

OBJECTIVE: To evaluate the outcome of pregnancies among Hispanics in a tertiary care hospital in Miami, Florida. STUDY DESIGN: Retrospective study of all women who delivered in our institution over an 11-year period. Outcome variables were stratified by race/ethnicity groups: Hispanics, non-Hispanic blacks and non-Hispanic whites. Variables included rates of low birth weight (LBW), preterm delivery (PTD) and other selected pregnancy outcomes. RESULTS: Thirty-five percent were of Hispanic origin, mainly of Caribbean, Central American and South American origin. Hispanics had the lowest rate of LBW (9%) when compared to blacks, non-Hispanics (18%) and white non-Hispanics (11%) (p < 0.0001). Hispanic women were less likely to deliver prematurely, at < 37 weeks (adjusted odds ratio [AOR] 0.68, 95% CI 0.65-0.91, p < 0.0001), < 32 weeks (AOR 0.57, 95% CI 0.52-0.63, p < 0.0001) and < 28 weeks (AOR 0.66, 95% CI 0.51-0.65, p < 0.0001). Hispanic women were less likely to have preterm premature rupture of membranes (AOR 0.66, 95% CI 0.58-0.75, p < 0.0001). CONCLUSION: Hispanics have the lowest PTD and LBW rates when compared to non-Hispanic whites and blacks.

Outcomes of pregnancies with sonographically detected nuchal cords remote from delivery.

OBJECTIVE: To evaluate the outcomes of pregnancies with sonographically detected nuchal cords remote from delivery during the second and third trimesters of gestation. METHODS: A retrospective study of patients with and without nuchal cords detected by sonography during the second and third trimesters of gestation (17-36 weeks) was conducted. Variables included maternal age, parity, gestational age at sonography and at delivery, method of delivery, intrapartum fetal heart abnormalities, meconium-stained amniotic fluid, birth weight, 5-minute Apgar score, and neonatal intensive care unit admissions. RESULTS: A total of 233 patients were included in this study, of which 118 had sonographically detected nuchal cords identified in our department during the study period. There were no statistically significant differences between patients with sonographically detected nuchal cords and control patients with respect to maternal age, estimated gestational age at sonography, method of delivery, meconium-stained fluid, birth weight, intrapartum fetal heart abnormalities, 5-minute Apgar scores of less than 7, and neonatal intensive care unit admissions. Patients with nuchal cords detected by sonography were more likely to give birth before 37 weeks' gestation than control patients (21% versus 11%; P = .040). CONCLUSIONS: A sonographically detected nuchal cord is not associated with important perinatal complications.

The effect of a single remote course versus weekly courses of antenatal corticosteroids on functional residual capacity in preterm infants: a randomized trial.

OBJECTIVE: There are no randomized data on the effect of repeat courses of corticosteroids during pregnancy on newborn pulmonary function. Our objective was to compare the effect of a single remote course of antenatal steroids (AS) with weekly courses of AS on functional residual capacity (FRC) and respiratory compliance in preterm infants. STUDY DESIGN/METHODS: Pregnant women 25 to 33 weeks' gestation, who remained undelivered 1 week after their first course of antenatal corticosteroids (two 12-mg doses of betamethasone) were randomized to weekly courses of corticosteroids versus weekly placebo until delivery or 34 weeks' gestation. FRC was measured with the nitrogen washout technique and respiratory compliance with the single breath occlusion technique within 48 hours of life. RESULTS: Thirty-seven infants (mean gestational age at delivery approximately 32.5 weeks) were studied. Maternal and infant demographics were similar. There was no significant difference in FRC (28.5 vs 27.5 mL/kg) or respiratory compliance between the infants who received a single remote course of antenatal corticosteroids and those who received weekly courses of corticosteroids until delivery. There was no significant difference in admission head circumference or birth weights between the groups. CONCLUSIONS: Our results demonstrate that weekly repetitive courses of AS do not significantly increase FRC or respiratory compliance in preterm infants when compared with a single remote course of steroids given at a mean gestational age of 29 weeks.