A school-, hospital- and university-based adolescent pregnancy prevention program. A cooperative design for service and research

Based upon prior service and research findings, a program was designed to reduce the incidence of early childbearing among a high-risk, inner-city junior and senior high school population. Combining a strong research design with medical and educational service in a school- and clinic-based program, the project team sought to develop a replicable model the individual components of which could be evaluated against baseline data collected from 1,709 male and female students before the program began. This paper reports levels of sexual activity, contraceptive use and pregnancy in the student population, using data from anonymous, self-administered questionnaires, and outlines the program's objectives and major features. It also suggests variables that can be used in the measurement of program impact.

Effect of intrauterine administration of tetracyclines on cynomolgus monkeys

Cynomolgus monkeys were used to screen for chemicals which potentially could be used as tubal occluding agents. Intrauterine administrations of solution or pellets of tetracycline and its analogues (100 mg doses) were tested for their effects on morphologic changes in the reproductive tract of monkeys. These effects were compared to monkeys receiving intrauterine administration of quinacrine pellets (36 mg) since quinacrine has been used successfully in the clinical setting. Blood levels of drugs, blood chemistry and hematology determinations and liver and kidney pathology data were also obtained as indices for toxicity. Morphologic damage to the uterine lining and intramural section of the tube (including necrosis, inflammation or scarring) was elicited by intrauterine tetracycline and doxycycline in the same frequency and severity as quinacrine. In contrast, saline or sham control monkeys showed no morphological damage of the tube or uterus. Although all drugs could be detected in the blood 4 hours after intrauterine administration, levels were near or below the limit of detection by one week. No evidence was found for toxicity of tetracycline or its analogues for the dosage given. Because of these results and the extensive literature on tetracycline toxicity, further studies should be directed toward the use of tetracycline as a sterilizing agent in women.

Comparison of the operating microscope and loupe for microsurgical tubal anastomosis: a randomized clinical trial

Reversal of sterilization was performed by microsurgical tubal anastomosis in 72 women using either loupe (n = 36) or microscope (n = 36). The study design called for the randomization of patients within pairs, which were matched for method of sterilization and site of anastomosis. A significant difference between methods could not be demonstrated at 12 months (P = 0.39) or 24 months (P = 0.37) after the procedure.

Microsurgical tubal anastomosis: a controlled trial in four Asian centers

An international program to determine the reversibility of female sterilization in Asia using microsurgical technique was established in 1980. One hundred eleven of 219 patients (51%) conceived following tubal anastomosis; of these, 79 delivered living children. The overall cumulative probability of conception at the end of follow-up, as determined by life-table analysis, was 63%. A decreased pregnancy rate was associated with anastomosis of tubes sterilized by electrocautery methods.

Pharmacokinetic studies on quinacrine following intrauterine administration to cynomolgus monkeys

Recent efforts have been made to develop a chemical oviductal occluding agent. Intrauterine quinacrine has been used in certain areas of the world with moderate success in effected tubal closure. This report presents the pharmacokinetics of a quinacrine solution (30 mg) as administered to cynomolgus monkeys via the intrauterine route, compared with intravascular injection. The data show rapid transfer of the drug from the uterine to the vascular compartment and uptake by almost all tissues examined. Although plasma concentrations disappear within 24 hours, levels can be detected in most tissues for at least 1 week following intrauterine injection. After 28 days, however, tissue levels of the drug are absent or near the limit of detection.

Cephalothin prophylaxis for midtrimester abortion

A randomized prospective double-blind study was conducted to determine the efficacy of prophylactic antibiotics as compared with placebo in 198 women undergoing second-trimester intraamniotic injection abortions. Patients received either sodium cephalothin or placebo intravenously before the procedure and for up to 8 additional doses. In 11 patients postabortion endometritis developed; 2 had received the antibiotic and 9 had received a placebo (P less than .05). Prophylactic cephalothin decreased the incidence of endometritis in patients undergoing midtrimester injection abortion. An injection-abortion interval greater than 24 hours appears to identify patients at risk for the development of postabortion endometritis.

Plasma lidocaine levels following paracervical infiltration for aspiration abortion

Convulsive morbidity has been associated with use of local anesthetics in a paracervical block performed for suction curettage. This complication appears to result from toxic blood levels of the local anesthetics employed. To evaluate the time course of lidocaine plasma levels following paracervical infiltration, plasma lidocaine determinations were obtained in 25 patients undergoing suction curettage without laminaria pretreatment and in 24 patients undergoing suction curettage after laminaria pretreatment. Paracervical block was administered using using 90 to 100 mg of lidocaine. Mean plasma lidocaine levels were higher in the laminaria group than in the group without laminaria. No patient reached clinically toxic drug levels. At the dosages employed, paracervical block appears to be a safe anesthetic for suction abortion procedures.

Roentgenographic pelvimetry in single vertex pregnancies

Of the 4,529 women delivered of infants at The John Hopkins Hospital during 1976 and 1977, 212 (5%) had roentgenographic pelvimetry. An analysis of a subgroup of 142 single vertex pregnancies with radiographic pelvimetry during this two-year period is presented. The cesarean section rate was 40% among patients selected for roentgenographic pelvimetry whose pelvis was found to be adequate. Vaginal delivery in women with a pelvis radiographically shown to be small was accomplished in 27% of patients with failure to progress in labor and in 22% of the patients with a fetus in the floating vertex presentation. Patients with a small pelvis who delivered vaginally had significantly smaller infants than those delivered by cesarean section (2,785 +/- 399 gm vs 3,146 +/- 433 gm). The only significant difference in pelvic measurements between these two groups occurred in the AP diameter of the inlet (11.5 +/- 1.1 cm vs 10.5 +/- 1.0 cm). Roentgenographic pelvimetry of single pregnancies as evaluated in this study appears to have limited clinical usefulness.

Adverse effects of cardiovascular drug therapy on the fetus and neonate

Possible adverse effects of cardiovascular medications on the fetus and the neonate have been reviewed. The major classes discussed were diuretics, antihypertensives, antiarrhythmics, cardiac glycosides, and anticoagulants. The recommendations given must not be considered definitive because they are based on flawed or incomplete information. It is to be hoped that further investigation will improve this situation and will also improve our understanding of the ways in which these drugs act.

The effects of chronic gastrointestinal medication on the fetus and neonate

The adverse fetal and neonatal effects of chronic gastrointestinal medication have been reviewed. The major classes discussed are antiemetics, laxatives and antidiarrheal agents, antacids and cimetidine, drugs for irritable bowel syndrome, and drugs for inflammatory bowel disease. The evaluation given are tentative due to the lack of information on most of these drugs. It is hoped that research into the use of this diverse group of medications during pregnancy will be stimulated, so that the large gaps in our knowledge about them can be filled.

Effect of silver nitrate on pregnancy termination in cynomolgus monkeys

The effect of intrauterine injection of 1% silver nitrate on pregnancy was studied in 13 cynomolgus monkeys. The monkeys received, in a random manner, intrauterine injections of 1 ml of either 1% silver nitrate (n = 7) or 0.9% NaCl solution (n = 6) between days 27 and 43 of pregnancy. Silver nitrate injection resulted in vaginal bleeding, beginning 1 or 2 days after treatment, that lasted for an average of 5.3 days. In all of these cases, pregnancy was terminated. Injection of normal saline had variable sequelae, but four of six monkeys were delivered of healthy offspring. All of the silver nitrate-treated animals recycled and, after remating, two of the seven subsequently became pregnant again and were delivered of normal healthy infants. This study demonstrates the efficacy of intrauterine injection of 1% silver nitrate in terminating early pregnancy.

Endometriosis and the development of tuboperitoneal fistulas after tubal ligation

The present study details gross and histologic findings of 79 previously ligated fallopian tubes from 3 groups of patients. Of 20 oviducts removed after documented sterilization failure (group I), 6 revealed a process compatible with endometriosis. Four of nine previously ligated fallopian tubes removed at the Johns Hopkins Hospital (group II) were successfully injected with India ink. In two patients histologic examination demonstrated the India ink in epithelium-lined spaces that lay beyond the muscle of the tubal wall extending from the tubal lumen to the serosal surface. Fifty oviducts were studied in twenty-five patients requesting reversal of their sterilizations (group III). A higher percentage of fistulas was demonstrated in patients with less than 4 cm of remaining proximal tubal segment. Furthermore, most of these fistulas were demonstrated in patients for whom 3 years had elapsed since the original sterilization procedure. Patients sterilzed by laparoscopic cautery methods were observed to have a higher percentage of fistula formation and histologic documentation of endometriosis at the sterilization site as compared with patients sterilized by other methods. Our observations suggest that ligation of the oviduct within 4 cm of the uterine cornu may predispose to the development of endometriosis and subsequent fistula formation in the tip of the ligated oviduct.

An international program for the assessment of tubal anastomosis by microsurgical technique: a preliminary report

This report outlines a microsurgical training program that has established 16 centers around the world for the reversal of sterilization by microsurgical technique and for the evaluation of such procedures. An obstetrician-gynecologist was selected from each of several developing countries where an existing family planning program was responsible for a large number of sterilization procedures. Each course participant attended a 2-week course in microsurgical techniques for tubal anastomosis and then returned to his or her home country to establish a microsurgical center for sterilization reversal. Each of these centers has since been evaluated by the program director and is fully operational.

The incidence of abdominal surgical procedures in a population undergoing abortion

The incidence of abdominal surgical procedures was determined in 11,885 patients undergoing termination of pregnancy. Thirty-eight abdominal surgical procedures were completed, an incidence of 3.9 per 1,000 abortion cases. Seventy-two percent were completed for the diagnosis and management of coexistent genital pathologic conditions, with the remainder required for the management of abortion complications. These data provide patients an estimate of their chances of having to undergo abdominal surgical procedures, prior to their making a final decision to have a pregnancy terminated.

Therapeutic implications of doxycycline and cephalothin concentrations in the female genital tract

The pharmacokinetics of doxycycline and cephalothin in genital tissues and serum were evaluated in 38 patients undergoing hysterectomy. Antibiotic concentrations in the ovary, fallopian tube, myometrium, cervix, and endometrium were measured at varying intervals after antibiotic administration. Cephalothin concentrations in tissues were critically dependent on the time interval between preoperative antibiotic administration and removal of the genital tract tissues, whereas doxycycline concentrations in tissues were consistently reproducible in the time frame evaluated (1/2 to 4 1/2 hours after drug administration). Doxycycline endometrial concentrations were consistently higher than those measured elsewhere in the genital tract (P less than 0.05). These results are of importance in a reassessment of traditional approaches to antibiotic use in gynecologic surgery and in the management of pelvic inflammatory disease (PID).

Gestational trophoblastic disease within an elective abortion population

Gestational trophoblastic disease, most commonly hydatidiform mole, is an unusual condition within the United States. The incidence of hydatidiform mole has been reported to vary from 1 in 1,200 to 1 in 2,000 pregnancies. This report described eight cases of hydatidiform mole among 4,829 patients presenting for elective first-trimester abortion. Factors which might account for the frequency of hydatidiform mole of 1 in 600 are discussed. Although the clinical course of patients with hydatidiform mole appears benign- gross examination of tissue obtained at suction curettage and the liberal use of histologic evaluation in questionable cases is required to make the diagnosis.

The relative significance of human placental lactogen in the diagnosis of retarded fetal growth

The purpose of this prospective study was to determine whether serial maternal venous hPL determinations could identify pregnancies resulting in growth-retarded infants from a selected population at presumed high risk for IUGR. Our results demonstrated that mean hPL levels in IUGR outcome pregnancies were significantly lower than normal after 33 weeks' gestation. Mean hPL was also lower in some pregnancies resulting in normal-weight neonates with abnormally low PI or short CHL, suggesting that these neonates, despite normal birth weight achievement, may represent previously unsuspected.