Postpartum contraception

Recently-delivered women who wish to avoid pregnancy should initiate contraception before ovulation. Since the return of ovulation is not predictable, regardless of the woman's lactation status and duration of postpartum amenorrhea, contraception should be initiated as soon as is reasonable after delivery. The choice of contraceptive method will depend on several factors, including: the woman's lactation status, the preference of the woman and her partner, and the health status of the newborns. For women who do not wish to have additional children, tubal sterilization through a minilaparotomy incision is the procedure of choice. For other women who are not lactating, all methods, with the exception of the use of cervical caps and diaphragms, may be initiated immediately after delivery. However, preference should be given to IUD use by lactating and non-lactating woman, especially for women who may not return for any additional postpartum care.

Interception by post-coital IUD insertion

After the development of postcoital hormonal interception, the postcoital use of IUDs to prevent pregnancy was proposed by Tatum. The major advantage of this treatment is that it avoids the use of the usual massive dose of estrogens (a very effective postcoital method) which is associated with nausea and vomiting. This is the 1st method to be effective up to 5 days after exposure, 3 days more than the estrogen treatment. It may also provide long-term contraception in women who wish to continue using the IUD. A major disadvantage of postcoital IUD use is that IUD insertion can produce serious complications if a patient has a vaginal or venereal infection or an asymptomatic cervicitis or even pelvic inflammatory disease (PID). After proper physical examination, suitable patients are selected from those requesting postcoital treatment. Cases involving rape are mostly excluded from these services; but, if they present early, proper work up and treatment can be performed within the time span of 5 days available for this method and it will still be possible to fit a postcoital IUD. The potential risk of future infertility should be considered as PID rates in nulliparous IUD users are up to 7 times higher than in nonusers. Young nulliparous, sexually active women--especially of the lower socioeconomic strata--are identified as high-risk patients. Over 70% of women requesting interception are nulliparous. Clients asking for postcoital insertion should be informed of its potential risk, as women under 25 years of age are more prone to infection. The risk of septic abortion exists if an IUD is inserted into a gravid uterus due to pregnancy resulting from unreported previous sexual intercourse. Septic abortion is a life-threatening condition. Out of several series, no pregnancies are reported in the month of treatment. The IUD preferred is the Multiload copper IUD or the copper T; the highest expulsion rate proved the Copper-7 Gravigard (Cu-7) inefficient. In suitable circumstances, the IUD can be the 1st choice in postcoital interception.

The titanium/silicone rubber clip for female sterilization

A composite titanium/silicone rubber clip has been developed for female sterilization. The 12.7 mm long metal clip is lined with silicone rubber and is bent round the Fallopian tube by means of an applicator that can be used laparoscopically. As tubal necorsis occurs, the rubber expands to keep the lumen blocked. The tube eventually divides and the stumps heal closed. Since the Mark 3 version of the clip was introduced, over 5700 women in several countries have been sterilized. The first 540 British women who were followed-up for five to 17 months experienced one method failure (ectopic) and tow operator failures, to total failure rate of 5.5/1000. Clip-related complications were minimal and long-term sequelae were comparable to tubal ligation. The clip causes minimal destruction but still seems effective for tubal occlusion and it can accommodate thick tubes.

[Intrauterine contraception with copper-T 200 device- a retrospective analysis of 334 cases (author's transl)]

A review is given of the findings obtained in 334 women in whom a Cu-T 200 intrauterine device had been inserted at least two years previously and regular follow-up examinations were subsequently undertaken. The most frequent indications were an expressed preference for IUD on the patient's part (38.3%), poor tolerance to the "pill" (24.8%) and so-called "pill fatigue" (11.1%). Varicose veins led to IUD preference in 8.1% and thromboembolic disease in 6.-%. The failure rate - with 12 pregnancies - was 3.6%, all within 6 months of insertion of the device. Half of the pregnancies went to full term and resulted in the birth of mature, healthy babies. The most frequent complication were menstrual disturbances (20.1%). pain (19.5%), cervicitis (18.3%), and adnexitis (13.8%), necessitating removal of the device in 5.7%, 4.2%, 5.1%, and 0.6% of all cases for the afore-mentioned reasons, respectively. These rates are relatively high. The expulsion rate of 2.7% was relatively low, however. Further analysis of the complications led to the observation that menorrhagia was relatively common in nulliparae and in women with retroversion of the uterus, whereas the pre-insertion finding of a pressure-sensitive uterus with a normal ESR, led in a significantly higher percentage of cases to pain and adnexitis. The diagnosis by vaginal probe of a reduced uterine length led to faulty positioning and an increased tendency to pain in a significantly higher number of cases. The fact that only 56.6% of all women tolerated intrauterine contraception well and remained totally symptom-free supports th view held by us that even today the "pill" remains the contraceptive of choice and should be recommended as such.

Bacterial cultures from intrauterine devices removed from patients with pelvic inflammatory disease

Bacterial cultures were obtained from intrauterine devices (IUD) removed from 274 patients admitted to the Department of Obstetrics and Gynecology of the University Central Hospital of Helsinki because of suspected pelvic inflammatory disease (PID), meno-metrorrhagia, pain or other conditions potentially caused by an IUD. A diagnosis of serious PID was made in 42 patients, mild PID in 119 patients, while 113 were found to have no infection. An association between positive cultures of beta-hemolytic streptococci and Escherichia coli and PID was found. Positive cultures of Neisseria gonorrhoeae were significantly correlated with PID. The risk of developing PID was significantly greater during the first month after insertion of the IUD than when more than 30 days had elapsed from insertion of the IUD. The significance of the microbes cultured from removal IUDs as causal agents of pelvic inflammatory disease is discussed.

Clinical aspects of acute pelvic inflammatory disease: Cook County Hospital

We reviewed Cook County Hospital records of 134 consecutive patients hospitalized for acute pelvic inflammatory disease unrelated to intrauterine devices, delivery, or pelvic surgery. Nearly half our patients had peritonitis or a pelvic mass and most were young or nulliparous. Neisseria gonorrhoeae was recovered from the endocervices of 41 (34%) of 120 patients and was more common among younger patients. Most patients responded to antibiotic therapy; consequently, we recommend antibiotic treatment for acute PID unless surgical emergencies cannot be excluded or patients do not improve with antibiotic therapy alone.

Problems and approaches in the surveillance and control of sexually transmitted agents associated with pelvic inflammatory disease in Africa

The problems in surveillance of sexually transmitted disease (STD) in Africa are numerous and are based mainly on socioeconomic barriers. Policies for controlling STD are either inadequate or nonexistent in many African countries. Gonococci are becoming increasingly insusceptible to penicillin and other drugs because of widespread use of inadequate therapy. Gonorrhea is recognized as the major pathogen of pelvic inflammatory disease in Africa. The magnitude of the PID problem is so great that current efforts are directed at case treatment rather than surveillance and control. The formation of the African Union Against Venereal Diseases and Treponematoses is an important step, and its suggestions and resolutions form a sound basis for improved STD control in Africa.

Differences in some clinical and laboratory parameters in acute salpingitis related to culture and serologic findings

Women with laparoscopically verified acute salpingitis (AS) were studied, and 151 were classified as having: chlamydia-associated AS (C-AS), gonococcal-associated AS (G-AS), and nonchlamydial, nongonococcal-associated AS (NCNG-AS). Patients with G-AS were more often febrile (rectal temperature greater than 38 degrees C) and more often had a moderately elevated erythrocyte sedimentation rate (ESR) (16 to 30 mm/hr) compared to other patients. Women with NCNG-AS were more likely to have a normal ESR and a mild inflammatory reaction laparoscopically. C-AS women were more likely to have had pelvic pain for more than 3 days before seeking treatment and to have an ESR of greater than 30 mm/hr on admission. Predisposing factors to AS, such as insertion of intrauterine device, hysterosalpingography, and curettage within 4 weeks of admission, were more common in the C-AS group. The tubal inflammatory changes in the C-AS group were generally more severe than expected from the relatively benign clinical course.

Frequency and distribution of salpingitis and pelvic inflammatory disease in short-stay hospitals in the United States

Pelvic inflammatory disease is not a reportable condition in the United States. Based on data extracted from the Hospital Discharge Survey conducted by the National Center for Health Statistics, this article presents estimates of the frequency and distribution of PID in short-stay hospitals from 1970 through 1975.

Chlamydia trachomatis infection in patients with laparoscopically verified acute salpingitis. Results of isolation and antibody determinations

Culture and serology studies have shown Chlamydia trachomatis (CT) to be one of the causes of acute salpingitis (AS). In the present investigation, results of cervical cultures were correlated with serum antibody titers to CT in patients with laparoscopically verified AS. Serum samples from 206 patients, including paired sera from 80, were assayed. Of 206 patients, 118 had chlamydial IgG antibody titers of 1:64 or more. Patients with negative cultures for CT and an IgG titer of 1:64 or more had a significantly higher geometric mean titer than corresponding patients with positive cultures. In paired sera, a seroconversion or a fourfold or greater rise in IgG titer to CT was demonstrated in 35%, while a further 11% had detectable IgM antibody in a titer of 1:8 or more. The overall isolation frequency of CT was 33%, compared with 19% for Neisseria gonorrhoeae.

Problems in the diagnosis of ectopic pregnancy

Problems in the diagnosis of ectopic pregnancy have been assessed over a 4-month period at King Edward Memorial Hospital. Twenty-three of thirty women (77%) were sent home after their initial presentation with symptoms of their ectopic pregnancy. Thirteen were sent home from major teaching hospitals and the remaining 10 by their general practitioners. In 76 patients, laparoscopy was performed to exclude ectopic pregnancy; the diagnosis was confirmed in only 30. Plasma beta HCG values were elevated in all patients with an ectopic pregnancy within the Fallopian tube. The finding of a beta HCG value of less than 2.5 i.u./l could have allowed 36 of these patients to avoid diagnostic laparoscopy. Nine patients with intrauterine pregnancies (5 continuing and 4 aborting) might have avoided laparoscopy if ultrasonography had been used. Careful application of these tests, together with good history taking, will minimise the number of patients in whom an incorrect diagnosis is made.