Pregnancy in systemic lupus erythematosus

Fertility is usually normal in systemic lupus erythematosus. However, cyclophosphamide therapy has been associated with an increased risk for sustained amenorrhea in these patients. There is still debate as to whether pregnancy increases systemic lupus erythematosus activity. We have known for decades that systemic lupus erythematosus is associated with an increased risk for pregnancy loss. Now we know that most excess fetal loss in women with systemic lupus erythematosus occurs in association with antiphospholipid antibodies, which also are associated with pregnancy loss in otherwise healthy women. Prematurity, intrauterine growth retardation, and preeclampsia are common features of lupus pregnancy, especially in women with antiphospholipid antibodies. Pregnancy complicated by antiphospholipid syndrome requires expert care and a team approach involving obstetricians, obstetric physicians, rheumatologists, and clinical hematologists. Treatment and close monitoring including uterine artery Doppler scans and timely delivery may improve fetal outcome in these cases. Although there is no evidence that maternal prednisone should be used prophylactically, fluorinated steroids may be efficacious after in utero identification of congenital heart block, especially in fetuses with associated myocarditis.

Factors related to planned and unplanned pregnancies

BACKGROUND

Given the efficacy of most contraceptive options, it is of concern that most pregnancies in the United States are unplanned. Besides reducing the woman's and family's preparedness for parenting, unplanned pregnancies are at higher risk for inadequate prenatal care, perinatal morbidity, and significant postnatal problems. Little is known about the factors responsible for the high rates of unplanned pregnancy.

METHODS

One hundred ten pregnant women were surveyed to examine factors relating contraception to unplanned pregnancy.

RESULTS

Sixty-five percent of pregnancies were unplanned. There was a statistically significant association between having unplanned pregnancies and being single or divorced. Women who had planned their pregnancies tended to be more satisfied with contraceptives. In sexual encounters, women with unplanned pregnancies were more likely to use no contraception or to practice "withdrawal" or use condoms rather than hormonal contraception; to be influenced by their partner regarding birth control use; and to forget to use contraception.

CONCLUSIONS

All women of childbearing age who are sexually active can benefit from planning pregnancies. Counseling that accesses a woman's expectations regarding birth control, followed by a careful explanation of the side effects of a contraception choice, may reduce the rate of unplanned pregnancy. Counselling the male partner or sexually active men in contraceptive options may be equally important. Understanding factors that result in satisfaction with contraception may reduce unplanned pregnancies.

[Extrauterine pregnancy: epidemiology and etiology]

The aim of the present study is to determine the epidemiological characteristics and etiological factors of ectopic pregnancy. The pool of women at risk is determined by different factors such as contraceptive practices, fertility rate, sterilization, gynecological and pelvic infection. Serological evidence of previous Chlamydia infection was much more common when ectopic pregnancy occurred in abnormal tubes than in normal tubes or compared to intrauterine pregnancies. The influence of endometriosis and ovarian cyst was limited to a very few cases. The analysis of contraceptive habits shows a much higher number of extrauterine pregnancies (45%) when the woman is using progestin-only pill than when she is on combined oral tablets (20%). This higher rate of ectopic gestation can be interpreted to suggest either that the POP might be less effective in preventing ectopic than intrauterine pregnancies or that the POP can delay ovum transport by inhibiting the motility of the fallopian tube.

[Contraception with levonorgestrel subdermal implants. A Tunisian study]

OBJECTIVES

We report our experience in Tunisia with contraception by subdermal levonogestrel implants.

METHODS

From January 1, 1990 through June 30, 1994 we inserted 1021 implants at our family planning center in Ariana.

RESULTS

Our experience with this pure progesterone implant showed that this method provides effective long-duration contraception. There was only one case of ectopic pregnancy among our 1021 patients. The most frequent undesirable effect and the first cause of discontinuing treatment was disturbed menstrual cycle with irregular discharge.

CONCLUSION

Our results underline the importance of counselling before implant insertion. A 10-day estrogen regimen may provide a solution for menstrual disorders.

Breast cancer and hormonal contraceptives: collaborative reanalysis of individual data on 53 297 women with breast cancer and 100 239 women without breast cancer from 54 epidemiological studies

BACKGROUND The Collaborative Group on Hormonal Factors in Breast Cancer has brought together and reanalysed the worldwide epidemiological evidence on the relation between breast cancer risk and use of hormonal contraceptives. METHODS Individual data on 53 297 women with breast cancer and 100 239 women without breast cancer from 54 studies conducted in 25 countries were collected, checked, and analysed centrally. Estimates of the relative risk for breast cancer were obtained by a modification of the Mantel-Haenszel method. All analyses were stratified by study, age at diagnosis, parity, and, where appropriate, the age a woman was when her first child was born, and the age she was when her risk of conception ceased. FINDINGS The results provide strong evidence for two main conclusions. First, while women are taking combined oral contraceptives and in the 10 years after stopping there is a small increase in the relative risk of having breast cancer diagnosed (relative risk [95 percent CI] in current users 1.24 [1.15-1.33], 2p<0.00001; 1-4 years after stopping 1.16 [1.08-1.23], 2p=0.00001; 5-9 years after stopping 1.07 [1.02-1.13], 2p=0.009). Second, there is no significant excess risk of having breast cancer diagnosed 10 or more years after stopping use (relative risk 1.01 [0.96-1.05], NS). The cancers diagnosed in women who had used combined oral contraceptives were less advanced clinically than those diagnosed in women who had never used these contraceptives for ever-users compared with never-users, the relative risk for tumours that had spread beyond the breast compared with localised tumours was 0.88 (0.81-0.95; 2p=0.002). There was no pronounced variation in the results for recency of use between women with different background risks of breast cancer, including women from different countries and ethnic groups, women with different reproductive histories, and those with or without a family history of breast cancer. The studies included in this collaboration represent about 90 percent of the epidemiological information on the topic, and what is known about the other studies suggests that their omission has not materially affected the main conclusions. Other features of hormonal contraceptive use such as duration of use, age at first use, and the dose and type of hormone within the contraceptives had little additional effect on breast cancer risk, once recency of use had been taken into account. Women who began use before age 20 had higher relative risks of having breast cancer diagnosed while they were using combined oral contraceptives and in the 5 years after stopping than women who began use at older ages, but the higher relative risks apply at ages when breast cancer is rare and, for a given duration of use, earlier use does not result in more cancers being diagnosed than use beginning at older ages. Because breast cancer incidence rises steeply with age, the estimated excess number of cancers diagnosed in the period between starting use and 10 years after stopping increases with age at last use: for example, among 10 000 women from Europe or North America who used oral contraceptives from age 16 to 19, from age 20 to 24, and from age 25 to 29, respectively, the estimated excess number of cancers diagnosed up to 10 years after stopping use is 0.5 (95 percent CI 0.3-0.7), 1.5 (0.7-2.3), and 4.7 (2.7-6.7). Up to 20 years after cessation of use the difference between ever-users and never-users is not so much in the total number of cancers diagnosed, but in their clinical presentation, with the breast cancers diagnosed in ever-users being less advanced clinically than those diagnosed in never-users. The relation observed between breast cancer risk and hormone exposure is unusual, and it is not possible to infer from these data whether it is due to an earlier diagnosis of breast cancer in ever-users, the biological effects of hormonal contraceptives, or a combination of reasons...

Determination of urinary metabolites of caffeine for the assessment of cytochrome P4501A2, xanthine oxidase, and N-acetyltransferase activity in humans

Caffeine metabolism via the 3-demethylation pathway is sequentially catalyzed by cytochrome P4501A2 (CYP1A2), xanthine oxidase, and N-acetyltransferase. The activities of the three enzymes can be estimated from urinary metabolic ratios of four caffeine metabolites, 5-acetylamino-6-formylamino-3-methyluracil (AFMU), 1-methyluric acid (1MU), 1-methylxanthine (1MX), and 1,7-dimethyluric acid (17DMU), after the ingestion of caffeine. A method for quantitation of the four metabolites in human urine has been developed. The method is based on a one-step extraction with ethyl acetate/2-propanol followed by high-performance liquid chromatography with UV detection. The detection limit was 1 microM for AFMU, 1MU, and 1MX and 2 microM for 17DMU. The intraday and interday coefficients of variation were < 3% and < 7%, respectively, and the accuracy was within +/- 3%. The method was employed in a population study of 277 healthy volunteers, each of whom ingested 200 mg caffeine and provided a urine sample approximately 6 h later. The metabolite concentration ranges in the urines were 2.1-327 microM, 4.0-744 microM, 4.9-598 microM, and 6.4-260 microM for AFMU, 1MU, 1MX, and 17DMU, respectively. The CYP1A2 ratio (AFMU + 1MU + 1MX/17DMU) was significantly lower in women than in men, excluding smokers and oral contraceptive users. The CYP1A2 ratio was higher in smokers than in nonsmokers, confirming the induction of CYP1A2 by smoking. In women using oral contraceptives, the CYP1A2 ratio was, as expected, significantly lower than in women not using oral contraceptives. For the N-acetyltransferase ratio (AFMU/1MX) and the xanthine oxidase ratio (1MU/1MX), no differences were seen in terms of sex, smoking habits, or the use of oral contraceptives. All results are in agreement with previous reports on CYP1A2, N-acetyltransferase, and xanthine oxidase activities in humans. Thus, the method is both analytically and biologically reliable for the assessment of CYP1A2, N-acetyltransferase, and xanthine oxidase in humans.

[APC (activated protein C) resistance and oral contraceptives]

Resistance to activated protein C [1,2,3,4,5,6] is the most frequent hereditary cause of thromboses and is widespread through-out the population. Women with APC resistance have an enhanced risk of thrombosis compared to the total population. The risk increase, with the intake of oral contraceptives.

Progestins

The history of progesterone and hormone replacement therapy goes back to 1934 when Butenandt obtained crystalline progesterone and Kaufmann started to treat ovariectomized women with both estrogens and progesterone (Table 1). Today synthetic perorally active 19-nortestosterone and 17-alpha-hydroxyprogesterone derivatives are used in addition to contraception and hormone replacement therapy in a variety of gynecological disorders. In hormone replacement therapy progestin is added only to prevent development of hyperplasia of the endometrium and its consequences. However, because progestins may cause both subjective and metabolic adverse effects minimum effective antiproliferative doses are recommended. The duration of the progestin phase cannot be shortened to less than 10 days whereas the frequency of administration apparently can be reduced without increased risk of hyperplasia. Development of new modes of administration may further help in reduction of the doses.

[Contraceptive use in women with heart disease]

PURPOSE

To analyse efficacy, tolerance and adverse events of reversible contraceptives in women with cardiac disease.

METHODS

We studied prospectively during 24-39 (mean = 29) months, 89 women with heart disease with a mean age of 25.6 (16-42) years. Rheumatic heart disease was present in 73 (82%) cases, congenital heart disease in 11 (11%), coronary artery disease in 2 (2%) and cardiomyopathy in 3 (3%) case. The patients were divided in three groups: GCO--35 patients taking combined oral contraceptives (30 micrograms ethinyl estradiol and 75 micrograms gestodene--COs); GIT--27 using injectable progestagens (depot medroxyprogesterone acetate-DMPA) and GUID--27 with intrauterine device (IUD).

RESULTS

In GCO occurred 4 (11.4%) cases of arterial hypertension, 1 (2.8%) of a transient cerebral isquemic attack, 3 (8.5%) of spotting, 1 (2.8%) of amnorrhea e 1 (2.8%) pregnancy. Interruption of this method occurred in 4 (11.4%) cases due to hypertension (2), pregnancy (1) and amenorrhea (1). In group GIT there were 2 (7.4%) cases of arterial hypertension, 18 (66.6%) of amenorrhea, and 3 (11.1%) of spotting. Interruption of use occurred in 5 (18.5%) due to amnorrhea (2), weight gain (2) and headache (1). In GUID there was 1 (3.7%) case of infeccion, 1 (3.7%) pregnancy and 1 (3.7%) spontaneous expulsion of IUD. Interruption of use took place in 3 (11.1%) cases due to infeccion, pregnancy and expulsion. The comparation between the groups demonstrated a difference in the incidence of amenorrhea (p < 0.005) and descontinuation of use of the method (p < 0.025).

CONCLUSION

Use of reversible contraceptives in heart disease women was associated with an acceptable cardiovascular risk. Efficacy and side effects of the methods were comparable in the groups, however intolerance was more observed in GIT.

Oral contraceptives and cancer. A review of the evidence

The following review considers epidemiological data published from 1990 onwards on oral contraceptives (OCs) and the risk of cancers of the breast, cervix uteri, endometrium, ovary, liver and skin. In several studies, breast cancer risk was seen to be elevated among women who were current users of an OC, or had recently stopped using an OC, whereas there was no residual risk 5 or more years after stopping OC use. No interaction was observed between type of OC, or with any recognised risk factor for breast cancer, or time-factor, except for some potential excess risk for women who started OC use at a young age. Most studies have confirmed that OCs moderately increase the risk of cervical cancer, particularly in human papilloma virus (HPV)-positive women, thus suggesting that OCs may act as a promoter for HPV-induced carcinogenesis. Recent epidemiological studies have confirmed that combined OCs provide substantial protection against endometrial and ovarian cancers, and results suggest that such protection is long-lasting, and may persist for 15 years or more after stopping OC use. Most case-control studies have shown a relationship between OC use and hepatocellular carcinoma. However, data from cohort studies or analysis of vital statistics indicate that the public health impact of such an association is modest, if not negligible. No association was observed between combined OC use and the incidence of skin melanoma, or any other common skin neoplasm. In terms of clinical and public health implications, the most relevant points regarding OC use are: (i) recent data confirm that OCs confer presistent protection against ovarian cancer; and (ii) any increased risk of breast cancer in OC users is moderate and is restricted to current/recent users. This is reassuring for younger women, whose baseline risk of this disease is extremely low.

Erythema multiforme

The diagnosis of erythema multiforme was established on the basis of physical examination, biopsy specimen evaluation, and the patient's medication history. Use of a triamcinolone mouthrinse and discontinuation of Triphasil-28 contraceptive led to resolution of the lesions.

The role of thromboxane A2 in increased whole blood platelet aggregation in oral contraceptive users

Epidemiological studies have shown that oral contraceptives increase the risk of thromboembolic disease in susceptible women however the mechanisms involved are unclear. We investigated whole blood platelet aggregation in 44 women randomly allocated to 6 cycles of treatment with either gestodene (75ug) or desogestrel (150ug) combined with 30ug ethinyloestradiol (EE). The in vitro effects of aspirin and a thromboxane synthetase inhibitor, dazmegrel (UK38485) were also investigated. Oral contraceptive treatment caused a significant increase in collagen, arachidonic acid (AA) and ADP induced whole blood platelet aggregation. PAF induced aggregation was unchanged. There were no significant differences in the levels of platelet aggregation between the desogestrel/30ugEE and gestodene/30ugEE groups. In vitro incubation of platelets with aspirin and dazmegrel prevented the oral contraceptive induced increase in platelet aggregation. Dazmegrel caused an on treatment decrease in PAF induced aggregation in the desogestrel/30ugEE but not the gestodene/30ugEE group. The results of this study indicate that the use of oral contraceptives is associated with an increase in platelet aggregation that is mediated by changes in thromboxane/prostacyclin ratio(TXA2/PGI2). Although no significant differences were found between the two different progestogen combinations, the effects of dazmegrel on PAF induced aggregation suggest a possible difference in the progestogen modifying effects of desogestrel and gestodene which is unmasked when thromboxane synthetase is inhibited.

Reference ranges and sources of variability of CD4 counts in HIV-seronegative women and men

BACKGROUND

CD4 lymphocyte counts are used to monitor immune status in HIV disease. An understanding of the variability of CD4 counts which occurs in the absence of HIV infection is essential to their interpretation. The sources and degree of such variability have not been extensively studied.

OBJECTIVES

To establish reference ranges for CD4 counts in HIV-seronegative women and heterosexual men attending a genitourinary medicine (GUM) clinic, and to identify possible differences according to gender and cigarette smoking and, in women, any effect of the menstrual cycle, oral contraceptive use and cigarette smoking.

DESIGN

Female and heterosexual male patients attending a GUM clinic and requesting an HIV-antibody test were recruited prospectively. Results from an earlier study of CD4 counts in homosexual men were available for comparison.

METHODS

Lymphocyte subpopulation analysis on whole blood by flow cytometry.

RESULTS

The absolute CD4 count and percentage of CD4 cells (CD4%) were significantly higher in women (n = 195) than heterosexual men (n = 91) [difference between the means 111 x 106/1 (95% CI 41, 180) and 3.1% (1.30, 4.88)]. The absolute CD4 count and CD4% were also significantly higher in smokers (n = 143) than non-smokers (n = 140) [difference 143 (79, 207) and 2.1% (0.43, 3.81)]. Reference ranges for absolute CD4 counts (geometric mean +/- 2SD) were calculated on log transformed data as follows; female smokers 490-1610, female non-smokers 430-1350, heterosexual male smokers 380-1600, heterosexual male non-smokers 330-1280. Among other variables examined, combined oral contraceptive pill use was associated with a trend towards a lower absolute CD4 count. Changes were seen in CD4% with the menstrual cycle. CD4 counts and CD4% did not differ significantly between heterosexual men and homosexual men (n = 45).

CONCLUSION

There is a significant gender and smoking effect on CD4 counts. The effects of oral contraceptive use and the menstrual cycle warrant further investigation.