A Social Media Survey of US Adolescent Preferences for Menstrual Bleeding Patterns

STUDY OBJECTIVE

To assess preferences for menstrual pattern and acceptability and knowledge about the safety of induced amenorrhea among adolescents and young adults METHODS: We conducted a cross-sectional online survey of US residents aged 14-24 years at least 1 year post-menarche. Online recruitment was conducted via the social media platform TikTok on a teen reproductive health channel. Survey questions focused on menstrual history, menstrual pattern preferences, and demographic characteristics. The primary outcome was the proportion of postmenstrual individuals who would prefer amenorrhea vs scheduled bleeding.

RESULTS

From 5113 potential respondents who accessed the eligibility screening, 3001 completed surveys and met the inclusion criteria. Most were aged 14-18 (63.7%), distributed proportionally among all US Census regions. When asked if they could pick their period-bleeding style without any permanent impacts, almost three-quarters chose no bleeding at all (amenorrhea; 71.5%) compared with scheduled periods (28.5%). However, 63.7% agreed or were uncertain when faced with the statement "It might be unsafe if hormone medications stop your period bleeding." After adjusting for age, gender expression, race, religion, heavy bleeding, and frequent bleeding, factors associated with preference for amenorrhea vs regular bleeding were younger age, masculine gender expression, White race, and non-Christian religious background. Baseline bleeding amount and frequency were not associated with preference for amenorrhea.

CONCLUSION

More than two-thirds of US adolescents and young adults indicated a preference for medication-induced amenorrhea if the method was assured to not have any permanent effects on the body, despite highly prevalent misconceptions about health and safety.

Menstrual Health Literacy among Adolescents and Young Adults Who Menstruate: Impact of Christian Family Background and United States Region

STUDY OBJECTIVE

To compare menstrual health literacy among adolescents and young adults on the basis of family religious background and United States region METHODS: We conducted a cross-sectional online survey of post-menarcheal US adolescents and young adults aged 14-24 years who identified their family religious background, including Christian or non-religious, with recruitment via the social media platform TikTok. We asked participants several questions to assess their health literacy regarding common myths about the use of gonadal steroid hormones for menstrual suppression.

RESULTS

From 3250 online survey respondents, 2997 met the criteria for analysis, with 1989 identifying their family as Christian (66.4%) and 1008 identifying their family as non-religious (33.6%), with equal representation by US region. Health literacy was lower among those with a Christian family background, with concerns that menstrual suppression is unhealthy (16.4% vs 10.5% with non-religious background, P < .01), is unsafe (31.4% vs 24.2%, P < .01), and could lead to infertility (32.6% vs 20.0%, P < .01). Similarly, adolescents and young adults from the US South were worried that menstrual suppression is unhealthy (31.5%; P < .01) and would lead to infertility (33.8%; P < .01).

CONCLUSION

Health literacy is lower among adolescents and young adults with a Christian family background and those who live in the South. These results demonstrate a need for an evidence-based national curriculum that addresses the safe and effective use of hormonal medications for menstrual suppression.

Nanomedicines for Improved Management of Ectopic Pregnancy: A Narrative Review

Ectopic pregnancy (EP) - the implantation of an embryo outside of the endometrial cavity, often in the fallopian tube - is a significant contributor to maternal morbidity and leading cause of maternal death due to hemorrhage in first trimester. Current diagnostic modalities including human chorionic gonadotropin (hCG) quantification and ultrasonography are effective, but may still misdiagnose EP at initial examination in many cases. Depending on the patient's hemodynamic stability and gestational duration of the pregnancy, as assessed by history, hCG measurement and ultrasonography, management strategies may include expectant management, chemotherapeutic treatment using methotrexate (MTX), or surgical intervention. While these strategies are largely successful, expectant management may result in tubal rupture if the pregnancy does not resolve spontaneously; MTX administration is not always successful and may induce significant side effects; and surgical intervention may result in loss of the already-damaged fallopian tube, further hampering the patient's subsequent attempts to conceive. Nanomaterial-based technologies offer the potential to enhance delivery of diagnostic imaging contrast and therapeutic agents to more effectively and safely manage EP. The purpose of this narrative review is to summarize the current state of nanomedicine technology dedicated to its potential to improve both the diagnosis and treatment of EP.

Glutathione-Responsive Methotrexate Polymersomes for Potential Management of Ectopic Pregnancy

The first-line treatment for ectopic pregnancy (EP), the chemotherapeutic methotrexate (MTX), has a failure rate of more than 10%, which can lead to severe complications or death. Inadequate accumulation of administered MTX at the ectopic implantation site significantly contributes to therapeutic failure. This study reports the first glutathione-responsive polymersomes for efficient delivery of MTX to the implantation site and its triggered release in placental cells. Fluorescence and photoacoustic imaging have confirmed that the developed polymersomes preferentially accumulate after systemic administration in the implantation site of pregnant mice at early gestational stages. The high concentrations of intracellular glutathione (GSH) reduce an incorporated disulfide bond within polymersomes upon internalization into placental cells, resulting in their disintegration and efficient drug release. Consequently, MTX delivered by polymersomes induces pregnancy demise in mice, as opposed to free MTX at the same dose regimen. To achieve the same therapeutic efficacy with free MTX, a sixfold increase in dosage is required. In addition, mice successfully conceive and birth healthy pups following a prior complete pregnancy demise induced by methotrexate polymersomes. Therefore, the developed MTX nanomedicine can potentially improve EP management and reduce associated mortality rates and related cost.

Hormonal therapies in females with blood disorders: thrombophilia, thrombosis, hemoglobinopathies, and anemias

There is widespread use of gonadal steroid hormone therapy for a variety of indications throughout the reproductive and postreproductive lifespan. These therapies may have particular benefits and specific risk among those with blood disorders, including inherited or acquired bleeding disorders, thrombophilia, thrombosis, or anemia. This clinical review is intended to provide a guidance for counseling and management of adolescent and adult biologic females with thrombophilic risk factors and/or thrombosis who require hormonal therapy. In general, synthetic estrogens present in contraceptive products should be avoided in those with a personal or strong family history of thrombosis or thrombophilias. In contrast, natural estrogens present in formulations for climacteric symptom management do not need to be avoided, and vaginal or transdermal formulations are preferred. Likewise, transdermal estradiol is preferred for gender-affirming hormone therapy and requires individualized assessment in those at high risk of thrombosis. Progestogens (either synthetic progestins or naturally occurring progesterone) can be used safely in nearly all patients. There is minimal safety evidence among anticoagulated patients at risk for thrombosis, which requires a patient-specific approach when discussing hormone therapies.

Building the foundation for a community-generated national research blueprint for inherited bleeding disorders: research to advance the health of people with inherited bleeding disorders with the potential to menstruate

BACKGROUND

People who have or had the potential to menstruate (PPM) with inherited bleeding disorders (BD) face particular challenges receiving appropriate diagnosis and care and participating in research. As part of an initiative to create a National Research Blueprint for future decades of research, the National Hemophilia Foundation (NHF) and American Thrombosis and Hemostasis Network conducted extensive all-stakeholder consultations to identify the priorities of PPM with inherited BDs and those who care for them.

RESEARCH DESIGN AND METHODS

Working group (WG) 4 of the NHF State of the Science Research Summit distilled community-identified priorities for PPM with inherited BDs into concrete research questions and scored their feasibility, impact, and risk.

RESULTS

WG4 identified important gaps in the foundational knowledge upon which to base optimal diagnosis and care for PPM with inherited BDs. They defined 44 top-priority research questions concerning lifespan sex biology, pregnancy and the post-partum context, uterine physiology and bleeding, bone and joint health, health care delivery, and patient-reported outcomes and quality-of-life.

CONCLUSIONS

The needs of PPM will best be advanced with research designed across the spectrum of sex and gender biology, with methodologies and outcome measures tailored to this population, involving them throughout.

Nano-Theranostic Modality for Visualization of the Placenta and Photo-Hyperthermia for Potential Management of Ectopic Pregnancy

Ectopic pregnancy (EP) is the leading cause of maternity-related death in the first trimester of pregnancy. Approximately 98% of ectopic implantations occur in the fallopian tube, and expedient management is crucial for preventing hemorrhage and maternal death in the event of tubal rupture. Current ultrasound strategies misdiagnose EP in up to 40% of cases, and the failure rate of methotrexate treatment for confirmed EP exceeds 10%. Here the first theranostic strategy for potential management of EP is reported using a near-infrared naphthalocyanine dye encapsulated within polymeric nanoparticles. These nanoparticles preferentially accumulate in the developing murine placenta within 24 h following systemic administration, and enable visualization of implantation sites at various gestational stages via fluorescence and photoacoustic imaging. These nanoparticles do not traverse the placental barrier to the fetus or impact fetal development. However, excitation of nanoparticles localized in specific placentas with focused NIR light generates heat (>43 °C) sufficient for disruption of placental function, resulting in the demise of targeted fetuses with no effect on adjacent fetuses. This novel approach would enable diagnostic confirmation of EP when current imaging strategies are unsuccessful, and elimination of EP could subsequently be achieved using the same nano-agent to generate localized hyperthermia resulting in targeted placental impairment.

Does a Bleeding Disorder Lessen the Efficacy of the 52-mg Levonorgestrel-Releasing Intrauterine System for Heavy Menstrual Bleeding in Adolescents? A Retrospective Multicenter Study

PURPOSE

The aim of this study is to compare the patient-reported bleeding outcomes and complication rates with the use of the 52-mg levonorgestrel-releasing intrauterine system (52-LNG-IUS) for treatment of heavy menstrual bleeding (HMB) among adolescents with and without a diagnosed inherited bleeding disorder (BD) within the first 12 months after insertion.

METHODS

Retrospective chart review was conducted of adolescents ages 14-21 years, with and without an inherited BD, who underwent 52-LNG-IUS insertion between September 2013 and February 2020 for the treatment of HMB.

RESULTS

One hundred forty-four 52-LNG-IUS insertions among 139 subjects were evaluated. Fifty-nine (41%) of these were among adolescents with a diagnosed inherited BD, and 85 (59%) were among those without a BD. Among subjects with follow-up, documentation of patient-reported bleeding outcome, and a retained IUS (92/144), both groups subjectively reported improvement in bleeding outcome, with 91.7% (33/36) of those with a BD and 94.6% (53/56) of those without a BD reporting that bleeding outcome was better than prior to IUS insertion (p = .675). There was no statistically significant difference in the rate of spontaneous expulsion (p = .233), with the rate of expulsion in the first 12 months after placement among those with a BD of 13.7% (7/51) and 6.8% for those without a BD (5/72).

DISCUSSION

Adolescents with HMB both with and without an inherited BD benefit from the 52-LNG-IUS for the treatment of HMB. Rates of spontaneous IUS expulsion are not statistically different regardless of the presence of a BD and are similar to rates found in other studies of intrauterine device use in adolescents.

Miles and days until medical abortion via TelAbortion versus clinic in Oregon and Washington, USA

BACKGROUND

Medical abortion provided via telemedicine is becoming more widely available, potentially decreasing travel time for in-person abortion evaluation.

METHODS

We conducted a retrospective chart review of all outpatient medical abortions from October 2016 through December 2019 at our academic medical centre in Portland, Oregon, USA. Using mifepristone administration logs, we identified patients who underwent abortion via direct-to-patient telemedicine or in clinic. Both groups had pre-abortion ultrasound examination. We extracted patient characteristics and geographic data to compare travel distance to clinic, ultrasound facility, and nearest advertised abortion clinic. We compared time from first contact until mifepristone ingestion and gestational age at mifepristone ingestion.

RESULTS

Median distance from mailing address to clinic for 80 telemedicine and 124 clinic medical abortions was 95 (range 4-377) and 12 (range 0-184) miles (p<0.01). Distance travelled to ultrasound facility was shorter for telemedicine patients (median 7 miles, range 0-150 vs 12 miles, range 0-184; p<0.01) excluding outliers >200 miles. Distance to nearest advertised abortion clinic was equal between groups (median 7 miles, p=0.4). Time to mifepristone administration (ingestion) was longer (11 vs 6 days; p<0.01) and median gestational age was higher (49 vs 44 days; p=0.01) for telemedicine.

CONCLUSIONS

Telemedicine increases the reach of abortion providers and provides care to more geographically distant patients. Patients chose telemedicine abortion even when they had an equidistant option, suggesting that patients value telemedicine for reasons other than geographic convenience. This telemedicine delivery model that included ultrasound testing prior to abortion resulted in up to a 5-day delay in abortion initiation, which was not clinically significant.

Expansion of a direct-to-patient telemedicine abortion service in the United States and experience during the COVID-19 pandemic

OBJECTIVE

To present updated evidence on the safety, efficacy and acceptability of a direct-to-patient telemedicine abortion service and describe how the service functioned during the COVID-19 pandemic.

STUDY DESIGN

We offered the study at 10 sites that provided the service in 13 states and Washington DC. Interested individuals obtained any needed preabortion tests locally and had a videoconference with a study clinician. Sites sent study packages containing mifepristone and misoprostol by mail and had remote follow-up consultations within one month by telephone (or by online survey, if the participant could not be reached) to evaluate abortion completeness. The analysis was descriptive.

RESULTS

We mailed 1390 packages between May 2016 and September 2020. Of the 83% (1157/1390) of abortions for which we obtained outcome information, 95% (1103/1157) were completed without a procedure. Participants made 70 unplanned visits to emergency rooms or urgent care centers for reasons related to the abortion (6%), and 10 serious adverse events occurred, including 5 transfusions (0.4%). Enrollment increased substantially with the onset of COVID-19. Although a screening ultrasound was required, sites determined in 52% (346/669) of abortions that occurred during COVID that those participants should not get the test to protect their health. Use of urine pregnancy test to confirm abortion completion increased from 67% (144/214) in the 6 months prior to COVID to 90% (602/669) in the 6 months during COVID. Nearly all satisfaction questionnaires (99%, 1013/1022) recorded that participants were satisfied with the service.

CONCLUSIONS

This direct-to-patient telemedicine service was safe, effective, and acceptable, and supports the claim that there is no medical reason for mifepristone to be dispensed in clinics as required by the Food and Drug Administration. In some cases, participants did not need to visit any facilities to obtain the service, which was critical to protecting patient safety during the COVID-19 pandemic.

IMPLICATIONS

Medical abortion using telemedicine and mail is effective and can be safely provided without a pretreatment ultrasound. This method of service delivery has the potential to greatly improve access to abortion care in the United States.

"False positive" urine pregnancy test results after successful medication abortion

OBJECTIVE

To examine the proportion of high-sensitivity urine pregnancy test (HSPT) results that were positive by time after successful medication abortion.

STUDY DESIGN

We used data from an ongoing study that provides mifepristone and misoprostol for medication abortion by direct-to-patient telemedicine and mail. Providers evaluated abortion outcomes by patient interview and clinical tests per clinical judgment and participant preference. We identified all participants enrolled July 2016 to September, 2020 who had an HSPT result and no indication of viable pregnancy after treatment. We used logistic regression to examine the association between the timing of the initial post-treatment HSPT, gestational age, and the proportion of HSPTs that gave a positive result.

RESULTS

Of the 472 participants in our analysis, 88 (19%) had positive initial HSPTs. The proportions that were positive at ≤20 days, 21 to 27 days, 28 to 34 days, and ≥35 days after mifepristone ingestion was 14 of 29 (48%), 15 of 58 (26%), 49 of 258 (19%), and 10 of 127 (8%), respectively (p < 0.001). Gestational age at mifepristone ingestion was not significantly related to positive HSPT results (p = 0.28). Multivariable logistic regression confirmed both findings and did not identify a statistically significant interaction between these variables. In the 67 participants who relied solely on further HSPTs to confirm abortion outcome, the median interval between the initial positive test and first negative test was 14 days.

CONCLUSIONS

The proportion of participants with positive HSPTs declined with time after successful medication abortion. However, nearly one-fifth of participants with complete abortion had positive tests 4 weeks after treatment.

IMPLICATIONS

HSPTs provide an inexpensive, convenient option for confirming success of medication abortion at home. However, a substantial minority of patients without ongoing pregnancy have positive HSPT results. Development of a symptom-based strategy for medication abortion outcome assessment without any confirmatory tests should be a priority.

Serum human chorionic gonadotropin decline following aspiration abortion in early pregnancy less than 42 days gestation

OBJECTIVE

To define serum human chorionic gonadotropin (hCG) decline following complete aspiration abortion.

STUDY DESIGN

We performed a secondary analysis of 86 patients who underwent uncomplicated aspiration abortion for ultrasound-confirmed pregnancy ≤42 days gestation and had serum hCG at the time of aspiration and within 3 days postprocedure.

RESULTS

Median hCG declines were 72.9% by day 1 (n = 14), 87.6% by day 2 (n = 50), and 92.8% by day 3 (n = 22). Ninetieth percentile declines were 67.8%, 81.5%, and 90.8%. Minimum hCG declines were 56.2%, 77.3%, and 83.2%. Trends did not vary by gestational age or by initial hCG <3000 mIU/mL.

CONCLUSION

Postprocedure hCG trend varies over the first few days in early gestation. At ≤42 days gestation, serial hCG decline at 1 day after completed aspiration abortion is greater than 50%, consistent with the decline observed in medication abortion.

IMPLICATIONS

This study confirms previously estimated human chorionic gonadotropin decline after aspiration abortion of at least 50% at 24 hours for completed procedure in very early gestations. Minimum declines on days 2 and 3 are approximately 70% and 80%.

Heavy menstrual bleeding in women on oral anticoagulants

BACKGROUND

Although heavy menstrual bleeding (HMB) is a known complication of anticoagulant therapy, rates of HMB in users of the direct oral anticoagulants (OACs) apixaban and rivaroxaban are largely unknown.

METHODS

We performed a retrospective cohort study of menstruating women prescribed rivaroxaban, apixaban and warfarin over a six-year period (2012-2018). The primary outcome was HMB requiring medical or surgical intervention. We used descriptive statistics and logistic regression to evaluate associations between OAC type, age, history of HMB, and the primary outcome.

RESULTS

We identified 195 women of reproductive-age with a new therapeutic OAC prescription (62 on rivaroxaban, 54 on apixaban, 79 on warfarin). A minority (26/195, 13.3%) had a documented history of HMB, including 9 rivaroxaban users, 7 apixaban users and 10 warfarin users but most women (117/195, 60%) had no menstrual history documented. One third of subjects (64/195) required treatment for HMB within 6 months of starting OAC therapy. After controlling for a history of HMB, rivaroxaban users were 1.4 times more likely to require treatment as compared to users of other OACs.

DISCUSSION

We found an association between rates of HMB necessitating medical or surgical intervention and rivaroxaban use. We also found that the majority of women did not have a documented menstrual history, suggesting that many providers do not inquire about menstrual bleeding when starting OAC therapy. Menstruating women, particularly those with a history of HMB, may be at increased risk for HMB necessitating medical treatment depending on the type of OAC used.

Pregnancy intention screening tools: a randomized trial to assess perceived helpfulness with communication about reproductive goals

Background

Federal and clinical guidelines support integration of reproductive life planning in the care of female patients to aid in the reduction of unplanned pregnancies. A multitude of tools have been created to help in the counseling component, but further research is needed regarding how and whether they facilitate patient-provider communication.

Research

We performed a randomized controlled trial to evaluate if patients report whether a detailed or simple pregnancy intention screening tool is helpful for communication of reproductive life plans. We compared a novel reproductive counseling aid, the Family Planning Quotient (FPQ), to a simple tool based on the One Key Question® (OKQ). Providers also evaluated whether they thought the tool used at the visit was helpful. We randomized 93 patients to complete a survey including identical demographic questions and either the FPQ or OKQ reproductive counseling tool. We did not provide further instructions to either the patient or provider. Following the visits, we collected 84 subject evaluations and 79 provider evaluations. A similar proportion of subjects using either reproductive counseling tool found it helpful in communicating their reproductive life plans to their providers (approximately 66%), but there was no difference between the two tools studied. Less than half of providers reported that the FPQ tool was helpful (FPQ: 16/43, 37.2% versus OKQ: 18/36, 50%; p = 0.25).

Conclusion

Two-thirds of patients reported either a detailed or simple reproductive plan screening tool was helpful to facilitate communication with their provider, but only half of providers found either tool helpful. Use of reproductive screening tools should be followed by patient-centered counseling to help patients meet their reproductive life goals.

Video compared to conversational contraceptive counseling during labor and maternity hospitalization in Colombia: A randomized trial

OBJECTIVE

Assess if video-based contraceptive education could be an efficient adjunct to contraceptive counseling and attain the same contraceptive knowledge acquisition as conversation-based counseling.

STUDY DESIGN

This was a multicenter randomized, controlled trial examining contraceptive counseling during labor and maternity hospitalization regarding the options of immediate postpartum contraception. At two urban public hospitals, we randomized participants to a structured conversation with a trained counselor or a 14-min video providing the same information. Both groups received written materials and were invited to ask the counselor questions. Our primary outcome was to compare mean time for video-based education and conversational counseling; secondary outcomes included intended postpartum contraceptive method, pre- and postintervention contraceptive knowledge, and perceived competence in choosing a method of contraception.

RESULTS

We enrolled 240 participants (conversation group=119, video group=121). The average time to complete either type of counseling was similar [conversational: 16.3 min, standard deviation (SD) ±3.8 min; video: 16.8 min, SD ±4.6 min, p=.32]. Of women intending to use nonpermanent contraception, more participants intended to use a long-acting reversible contraceptive (LARC) method after conversational counseling (72/103, 70% versus 59/105, 56%, p=.041). Following counseling, mean knowledge assessment scores increased by 2 points in both groups (3/7 points to 5/7 correct). All but two participants in the video group agreed they felt equipped to choose a contraceptive method after counseling.

CONCLUSIONS

Compared to in-person contraceptive counseling alone, video-based intrapartum contraceptive education took a similar amount of time and resulted in similar contraceptive knowledge acquisition, though with fewer patients choosing LARC.

IMPLICATIONS

Video-based contraceptive education may be useful in settings with limited personnel to deliver unbiased hospital-based, contraceptive counseling for women during the antepartum period.

Predictors for follow-up among postpartum patients enrolled in a clinical trial

OBJECTIVE

To identify risk factors for failure to attend postpartum follow-up within 3 months of delivery, including social support, intrinsic motivation, insurance type and prenatal care attendance.

STUDY DESIGN

This planned secondary analysis is derived from a randomized controlled trial of patients intending intrauterine device (IUD) use following their delivery (n=197). Subjects were postpartum from a vaginal or cesarean birth at ≥32 weeks' gestation. We obtained baseline demographics and certainty about their plan to receive a postpartum IUD. We administered validated scales for social support and intrinsic motivation at enrollment. We then reviewed health records for prenatal visits and any postpartum visit by 3 months and performed logistic regression to assess for predictors of follow-up.

RESULTS

A total of 38/197 subjects (19.3%) failed to attend any postpartum visit by 3 months. Subjects who failed to follow up were more likely to have Medicaid versus private insurance (92% versus 8%, p<.01). Income <$50,000, no car, younger age, unplanned pregnancy, unemployment, multiple children, missed prenatal visits and late initiation of prenatal care were also associated with failure to follow up. Higher scores for social support and goal-directed motivation were not significantly associated with follow-up.

CONCLUSIONS

In our cohort, we found that one in five participants did not attend a postpartum visit by 3 months. Several socioeconomic indicators are associated with loss to follow-up, most notably Medicaid insurance. Having high motivation and social support is not sufficient to predict successful follow-up.

IMPLICATIONS

The main predictors for not attending a postpartum visit are Medicaid insurance or limited prenatal care, and not social support or intrinsic motivation. Interventions to improve postpartum contraception uptake should focus efforts on provision of immediate postpartum contraception for this population.

Comparison of 3 dilation and evacuation technical skills models

BACKGROUND

Simulation training may improve patient safety, decrease trainer and trainee anxiety, and reduce the number of cases needed for competency. Complications associated with dilation and evacuation (D&E) have been directly related to provider skill level, yet no low-fidelity model has been formally described or evaluated in the literature for second-trimester D&E training.

OBJECTIVE

We report physicians' assessments of the realism of 3 D&E models to establish a composite training model.

METHODS

We surveyed experienced providers at 2 national conferences to evaluate 3 D&E models and rate each model's components on a Likert scale.

RESULTS

Fifty-five obstetrics-gynecology and family medicine physicians completed the survey. Most respondents rated 4 components of 1 model as somewhat realistic or very realistic. The components rated highest were the fetal parts (82% [45 of 55]) and placenta (60% [30 of 50]). This model was rated as more likely to be used in training by 80% (43 of 54) of participants than the 2 other models, as rated by 28% (15 of 54) and 9% (5 of 54) of participants.

CONCLUSIONS

A model made from a plastic bottle containing a stuffed fabric form with detachable parts has tactile similarity to a D&E procedure and should be further developed for testing and training.

The effect of long-acting reversible contraception on rapid repeat pregnancy in adolescents: a review

Repeat pregnancy within 2 years of a previous birth or abortion occurs in approximately 35% of recently pregnant female adolescents. The majority of these pregnancies are classified as unintended with about half ending in births and the remainder in abortions. Rapid repeat pregnancy (RRP) is associated with increased maternal and neonatal morbidity and continues a cycle of economic deprivation for young women and their families. Immediately following a pregnancy, most young women report an intention to avoid pregnancy in the near future, but many change their minds or become ambivalent within months. Lack of contraceptive use is more common among those teens that resume sexual intercourse earlier, live with a male partner, had a preterm delivery, or had an intended teen pregnancy. Adolescents who do not initiate a long-acting reversible contraceptive (LARC) method (intrauterine device or contraceptive implant) have up to a 35 times increased risk of RRP compared with their peers using LARC. Risk of RRP is decreased when LARC methods are initiated earlier after an abortion or within the postpartum period. This review will focus on the prevalence of RRP, the risk factors for RRP, and the effectiveness of strategies to reduce unintended RRP including counseling and early initiation of long-acting contraceptive methods.

Weight and visual field deficits in women with idiopathic intracranial hypertension

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a disorder of elevated intracranial pressure (ICP) with no identifiable cause, associated with papilledema, vision loss, and headache. Previous studies have observed a relationship between weight gain and vision loss in women with IIH. We retrospectively examined a population of women with IIH to determine an association between weight gain in the year before diagnosis and the presence of visual field deficits.

METHODS

This cross-sectional study included women who enrolled in the Intracranial Hypertension Registry (IHR) between 2003 and 2005 and met study criteria for IIH. Data were obtained from mailed questionnaires and review of registrant medical charts. Prevalence ratios were used to assess the relationship between weight measures during the year before diagnosis and abnormal visual field findings at diagnosis.

RESULTS

The study population consisted of 159 females aged 13-64. The mean weight of the study population 1 year before diagnosis was 92 kg (standard deviation [SD] 27 kg). Mean weight gain was 5 kg (SD 13 kg) over the year before diagnosis. Visual field findings at diagnosis were abnormal in 84% (n = 122) of study subjects. There was no association between visual field deficits and body mass index (BMI), weight gain, or percent change in ideal body weight (IBW).

CONCLUSIONS

Weight change over the year before diagnosis was not associated with visual field deficits at diagnosis in this registry population of women with IIH.

Lack of insurance and parity influence choice between long-acting reversible contraception and sterilization in women postpregnancy

BACKGROUND

Disparities in postpregnancy contraception utilization exist, with low-income women disproportionately undergoing sterilization. We assessed the impact of increased intrauterine device (IUD) availability on rates of female sterilization.

STUDY DESIGN

Hospital billing records were used to identify women with an IUD placement or sterilization within 1 year of a pregnancy at a university hospital between Oct 2005 and Jun 2007. Demographic data were compared between women receiving either an IUD or sterilization.

RESULTS

There were 365 sterilizations and 223 IUD placements during the study period. IUD placements doubled over the study period from 6% to 12% of all deliveries, while sterilizations remained stable at 11% (p<.001). Demographic variables were examined for women with either public or private insurance who had financial access to both sterilization (n=253) and IUD (n=223). Women receiving sterilization were slightly older (mean age 31 years versus 30 years, p=.03), of higher parity (median three versus two, p<.01), more likely to have had cesarean delivery (69% versus 31%, p<.001) and more likely to have public insurance (77% versus 23%, p<.001) than women who received IUD. Approximately 45% of women delivering in Oregon in 2007 were publicly insured (2010 Maternal and Child Health Update: States Make Progress Towards Improving Systems of Care. National Governor's Association, Table 6. Available at http://www.nga.org/files/live/sites/NGA/files/pdf/MCHUPDATE2010.PDF, accessed Nov 2011). After adjusting for age, parity and type of delivery, women choosing sterilization were more likely to have public insurance than women choosing IUD (odds ratio 8.4, 95% confidence interval 4.7-14.9, p<.0001).

CONCLUSIONS

Women choosing sterilization are more likely to have public insurance than women choosing IUD and may represent a continued trend toward nonreversible contraception among women of lower socioeconomic status despite available long-acting reversible methods.

Well-being at the end of life: Part 1. A research agenda for psychosocial and spiritual aspects of care from the patient's perspective

This article reviews the scientific literature concerning psychosocial and spiritual aspects of palliative care for the patient with cancer. It discusses 4 separate areas: the continuum of care, communication, spiritual and psychological issues, and psychotherapeutic and behavioural management of physical symptoms. Most of the research could be classified as fundamental according to the Cancer Control Framework of the National Cancer Institute of Canada. In some areas, even fundamental research was lacking. There is a need for clearer and more relevant definitions of the desired outcomes of interventions and also for the development of appropriate quantitative and qualitative methods. We must determine which interventions can be initiated earlier in the disease trajectory and can provide benefit at the palliative phase. Given the burden of suffering that palliative care aims to address, relatively little research in this area has been conducted.

Clearance of recombinant tissue factor pathway inhibitor (TFPI) in rabbits

The pharmacokinetics of recombinant tissue factor pathway inhibitor (TFPI) after an intravenous bolus injection was studied in rabbits. Clearance of TFPI was followed by measurement of the radioactivity of the 125I-labelled compound in the whole plasma or the trichloroacetic acid precipitate and by quantitation of the functional TFPI activity of the unlabelled compound using a tissue factor-induced coagulation assay. When iodinated TFPI was used, the ratios of the trichloroacetic acid precipitable counts vs. that of the whole plasma was about 1 in the first 10 min after TFPI injection, but this ratio gradually decreased to less than 0.5 after 2 h. This result suggested that the iodinated TFPI in the plasma was partially degraded after prolonged circulation in the animal. When unlabelled TFPI was used, the clearance of TFPI activity from the plasma exhibited bi-exponential elimination kinetics with a rapid alpha phase half-life (t1/2 alpha) of 2.3 min, and a terminal beta phase half-life (t1/2 beta) of 79 min. The plasma clearance was 4.2 ml kg-1 min-1. The tissue distribution of intravenously administered 125I-TFPI in the rabbit was studied using whole-body autoradiography. At 3 min after dosing, significant levels of TFPI were apparent in the liver, kidney, and other highly blood perfused tissues. Significant levels of 125I-TFPI-derived radioactivity were also apparent in the liver and kidney at 30 min after intravenous administration. The localization within the liver demonstrated a mottled appearance, suggesting regions of higher uptake within the liver. In the kidney, the outer cortex consistently revealed the highest activity.

Feeding studies in rats with mineral hydrocarbon food grade white oils

This investigation compared the effects of feeding rats diets containing food grade white oil processed by either conventional oleum treatment or the more modern method of catalytic hydrogenation. In two separate experiments, male or female Fischer-344 rats were given free access for 90 days to diets containing 0, 10, 100, 500, 5,000, 10,000, or 20,000 ppm of either oleum-treated white oil (OTWO) or hydrotreated white oil (HTWO). There were no mortalities and no adverse clinical signs associated with feeding either white oil. Treatment-related effects evidenced by hematological, clinical chemical, and pathological changes were generally dose-related and more marked in female than in male rats, and the OTWO caused a greater pathological response than the HTWO. Tissue residues of saturated hydrocarbons were up to 5.2 times higher in female rats than in males. Rats fed 5,000 ppm or more of either white oil showed dose-related alterations in several hematological and clinical chemistry variates associated mainly with hepatic damage or functional alteration. At necropsy, mesenteric lymph nodes were enlarged, and increases in weight of liver, kidney, and spleen were significant. Microscopic changes were characterized by multifocal lipogranulomata in mesenteric lymph node and liver. No changes were observed in rats fed OTWO or HTWO for 90 days at dietary concentrations of 10 or 100 ppm, equivalent to a minimum intake of 0.65 and 6.4 mg/kg/day, respectively. Differences in degree of pathological response associated with each oil may have been due to their differences in specification rather than processing method.

Human dose-excretion studies with the pyrethroid insecticide, cypermethrin

1. An analytical method for monitoring human exposure to cypermethrin has been developed, based on the detection of the free and conjugated forms of the urinary metabolite, the cyclopropanecarboxylic acid. 2. Four male subjects were given a single oral dose, ranging from 0.25 mg to 1.5 mg, of a 1:1 cis/trans mixture of cypermethrin, and urine was monitored for the free and conjugated cyclopropanecarboxylic acid. Urinary excretion of the individual metabolites (cis and trans isomers) was similar for the different dosages. Subjects excreted, on average, 78% of the trans isomer dose, and 49% of the cis isomer dose respectively in 24 h. 3. Thus, as in other mammals, ester cleavage and elimination of the cis and trans cyclopropanecarboxylic acid moieties in the free and conjugated form is a major route of metabolism of cypermethrin in man.

Effect of vocal disguise on judgments of speakers' sex and race

To determine the effect of speakers' attempts to disguise their voices on listeners' accuracy in judgments of speakers' sex and race, 26 speakers, 13 women and 13 men, recorded six sentences under three conditions: (a) in a normal manner, (b) in a manner in which they attempted to sound like a member of the opposite sex, and (c) in a manner in which they attempted to sound like a member of the black race. Three master tapes were constructed, one for each of the three conditions. A total of 40 judges, 20 in an experiment on sex identification and 20 in one on race identification, participated in two sessions, one for each of two tapes (control and disguise) in each experiment. In each session they were asked to judge the sex or race of the speaker of each sentence and, using a seven-point confidence rating scale, to indicate the over-all confidence in their judgments at the end of each session. Analysis indicated that, although listeners' accuracy for sex and race identification was greater under the control than disguised conditions for the majority of speakers, the differences between the two conditions were relatively small. Implications of these findings and suggestions for future research are discussed.

The metabolism of 3-chloro-4-fluoro-aniline in dog and rat

1. 3-Chloro-4-fluorol[14C]aniline, orally administered to a female dog (0.135 mg/kg), was eliminated in the urine as 2-amino-4-chloro-5-fluorophenyl sulphate (83% in 48 h). 2. When 3-chloro-4-fluoro[14C]aniline was administered orally to male rats (ca 2.3 mg/kg), the 0-24 h urine contained 2-amino-4-chloro-5-fluorophenyl sulphate (52% of the aniline dosed), N-(5-chloro-4-fluoro-2-hydroxyphenyl)acetamide (13%) and an unidentified metabolite (16%). 3. 2-Amino-4-chloro-5-fluorophenyl sulphate was identified after extraction as salts by proton and fluorine-19 magnetic resonance spectroscopy. N-(5-Chloro-4-fluoro-2-hydroxyphenyl)acetamide was identified by mass spectrometry and proton magnetic resonance spectroscopy.

Detoxication and bioactivation of endrin in the rat

1. Rats exhibit a sex difference in the rate of metabolism of endrin. 2. The major metabolite in both sexes is anti-12-hydroxyendrin which is excreted via the bile as the glucuronide. Male rats produce the metabolite at a higher rate than do females. 3. trans-4,5-Dihydroisodrin-4,5-diol is a minor metabolite. A mechanism for its formation is discussed. 4. There is a sex difference in the production and excretion of 12-ketoendrin which is observed as a urinary metabolite in male rat; the major urinary metabolite in female rats is anti-12-hydroxyendrin O-sulphate. 5. syn-12-Hydroxyendrin was not detected but may be an intermediate in the formation of 12-ketoendrin. 6. The formation of 12-ketoendrin is related to the acute toxicity of endrin.