A pilot clinical trial of ultrasound-guided postplacental insertion of a levonorgestrel intrauterine device

BACKGROUND

Postplacental intrauterine device (IUD) insertion is a safe, convenient and effective option for postpartum contraception. Few studies involve ultrasound-guided insertion, and none involve the levonorgestrel IUD or take place in the United States.

STUDY DESIGN

The study was conducted to assess the safety and feasibility of ultrasound-guided postplacental insertion of the levonorgestrel IUD following vaginal delivery in a U.S. residency program. Levonorgestrel IUDs were inserted under ultrasound guidance within 10 min of placental delivery by hand or using ring forceps. Subjects were examined at 4 and 10 weeks postpartum for evidence of expulsion or infection.

RESULTS

Thirty-four subjects were enrolled and 20 received an IUD. Follow-up data are available for 19 subjects over the 10-week follow-up period; 16 subjects returned for the 4-week follow-up, and 14 returned at 10 weeks. Two additional subjects could be contacted by telephone only. At 4 and 10 weeks postpartum, no subjects had evidence of infection. There were two expulsions (2/19, 10.5%) by 10 weeks postpartum. None of the subjects examined had a partial expulsion (intracervical location of the IUD).

CONCLUSIONS

In this pilot study, ultrasound-guided postplacental insertion of the levonorgestrel IUD was feasible and not associated with infection. The risk of expulsion was acceptable. Ultrasound-guided postplacental insertion of the levonorgestrel IUD may be an alternative to delayed insertion but warrants further study.

Copper T 380A IUD and magnetic resonance imaging

BACKGROUND

Concerns about women who have implanted or in situ medical devices undergoing magnetic resonance (MR) imaging engender the need for testing. Prior testing of the Copper T 380A intrauterine device (IUD) has been done using MR systems of 1.5 T or less. This study was performed to test this IUD in a MR system of 3.0 T.

MATERIALS AND METHODS

In vitro safety testing was done via the Copper T 380A IUD using a GE Signa LX 3.0-T MR system. Variables tested included deflection, torque, heating and artifact.

RESULTS

No significant deflection, torque, heating or artifact was found in this in vitro testing model.

CONCLUSION

The outcomes measured revealed no safety concerns for the use of the Copper T 380A IUD at 3.0 T under the conditions of testing. This finding is compatible with the new standards adopted by the American Society for Testing and Materials and the Food and Drug Administration (FDA), with a rating of "MR Conditional."

Contraceptive use and discontinuation: findings from the contraceptive history, initiation, and choice study

OBJECTIVE

The purpose of this study is to provide insight on the continuing high rate of unintended pregnancy among adult women.

STUDY DESIGN

Contracepting women were recruited while they waited for primary care appointments. A total of 369 completed the baseline questionnaire, and 145 oral contraceptive (OC) users were enrolled in a 5-week, diary-based study of adherence and sexual activity.

RESULTS

Most women who reported having discontinued OCs did so because of medical side effects, and most had switched to less effective methods. Among OC users, 26.4% had sexual intercourse on days they missed pills just before or after their placebo week. Nonadherence did not differ by socioeconomic factors or obesity.

CONCLUSION

Clinicians may need to encourage their patients to discuss their reasons for wanting to discontinue the use of an effective contraceptive method and assist them with their concerns or to switch to other effective methods to protect themselves from unintended pregnancy.

Body mass index and risk for oral contraceptive failure: a case-cohort study in South Carolina

PURPOSE

Studies have suggested that obesity is associated with an increased risk for oral contraceptive (OC) failure. We conducted a case-cohort study in South Carolina to examine the association between body mass index (BMI) and OC failure by using population-based data sources.

METHODS

Our cohort sample from the source population consists of 205 women who reported using OCs to prevent pregnancy on the 1999 Behavioral Risk Factor Surveillance System survey. The 153 women who reported using OCs at the time of conception on the 2000 Pregnancy Risk Assessment Monitoring System survey represent the case sample that arose from the source population. Logistic regression was used to obtain odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

In unadjusted models with normal BMI (20 to 24.9 kg/m(2)) as the comparison, greater BMI was associated significantly with OC failure (overweight [25 to 29.9 kg/m(2)], OR = 2.54; 95% CI, 1.18-5.50; and obese [> or =30 kg/m(2)], OR = 2.82; 95% CI, 1.05-7.58). After adjustment for education, income, and race/ethnicity, associations were attenuated and no longer statistically significant.

CONCLUSIONS

In this heterogeneous population, we found a suggestion that overweight and obese women may be at increased risk for OC failure. However, long-term prospective studies are needed to study this association in diverse populations.

Peripartum contraceptive attitudes and practices

During pregnancy and the postpartum period, women may be more receptive to different methods of contraception for postpartum use. Few studies have focused on the peripartum population. In this study, currently pregnant and postpartum women were surveyed about their attitudes toward contraception, particularly in relation to the index pregnancy. Important contraceptive attributes for women included reliability, efficacy, and safety during breast-feeding, especially in the postpartum period. Over 80% of women surveyed were using contraception prior to pregnancy, but nearly 20% were not satisfied with the method used. Dissatisfaction with their method was more likely among women whose pregnancy was unplanned (36% vs. 9%). Over 40% of peripartum women indicated a desire to change their contraceptive after delivery. Sixty-five percent of women had received only limited information about intrauterine contraception before the survey. The results indicate that childbirth has a profound effect on contraceptive priorities and desires, especially toward long-term methods.

Teaching contraception: an interactive presentation using managing contraception

OBJECTIVE

Our purpose was to determine whether an interactive medical student contraceptive teaching session results in improved knowledge gain or satisfaction when compared with a standard, didactic lecture.

STUDY DESIGN

An interactive lecture was compared with a standard lecture among third-year medical students at Oregon Health and Science University School of Medicine and Medical College of Georgia. Knowledge gain was assessed by comparing correct responses to a posttest with the students' own responses to the same questions given as a pretest before the lecture. Satisfaction with the lecture was assessed on a visual analog scale. Scores and satisfaction ratings were compared within and between lecture groups.

RESULTS

A total of 150 students participated. There was a significant increase in test scores within both the interactive and standard groups ( P < .0001 for both groups). The change in scores did not differ significantly between the groups ( P = .087). Although overall satisfaction was significantly greater with the standard lecture ( P = .004), it was high with both lectures.

CONCLUSION

Knowledge gain with the interactive lecture was equivalent to that with the standard lecture. Satisfaction with both learning formats was high.

Safety concerns and health benefits associated with oral contraception

Since the introduction of hormonal contraceptives in the 1960s, there have been a variety of both health benefits and safety concerns attributed to their use. In most instances, the noncontraceptive benefits of oral contraceptives (OCs) outweigh the potential cardiovascular risks. In fact, the probability of a patient experiencing a cardiovascular event while taking a low-dose OC is very low. However, smoking, hypertension, obesity, and diabetes are risk factors that must be taken into account when prescribing OCs. The neoplastic effects of hormonal contraceptives have been extensively studied, and recent meta-analyses indicate that there is a reduction in the risk of endometrial and ovarian cancer, a possible small increase in the risk for breast and cervical cancer, and an increased risk of liver cancer. Finally, many women will experience noncontraceptive health benefits with OCs that expand far beyond pregnancy prevention. Some of these benefits include reduction in menstrual-related symptoms, fewer ectopic pregnancies, a possible increase in bone density, and possible protection against pelvic inflammatory disease.

New contraceptive options

Almost one half of pregnancies in the United States are unintended. Primary reasons for the high rate of unplanned pregnancy include dissatisfaction with or underuse of effective contraceptive methods and poor compliance with contraceptive methods that require daily adherence. Several effective forms of contraception have become available in the United States within the past four years. The combined hormonal vaginal ring is inserted into the vagina for three weeks and then removed; after one ring-free week, a new ring is inserted. The contraceptive patch works in much the same way as oral contraceptive pills but requires only once-weekly application by the patient. A new intrauterine system that releases levonorgestrel provides the same contraception as traditional intrauterine devices but is associated with less menorrhagia and dysmenorrhea. The intrauterine system is highly effective and carries minimal risk of pelvic inflammatory disease. In providing counseling about contraception, the physician should consider the woman's preference and determine the likelihood of adherence to the regimen. In case of contraceptive failure, emergency contraception is effective.

Contraceptive efficacy and cycle control with the Ortho Evra/Evra transdermal system: the analysis of pooled data

OBJECTIVE

To present efficacy and cycle control data pooled from three pivotal studies of the contraceptive patch (Ortho Evra/Evra).

DESIGN

Three multicenter, open-label, contraceptive studies that included up to 13 treatment cycles.

SETTING

183 centers.

PATIENT(S)

3,319 women.

INTERVENTION(S)

Three consecutive 7-day patches (21 days) with 1 patch-free week per cycle.

MAIN OUTCOME MEASURE(S)

Contraceptive efficacy and cycle control.

RESULT(S)

Overall and method failure life-table estimates of contraceptive failure through 13 cycles were 0.8% (95% CI, 0.3%-1.3%) and 0.6% (95% CI, 0.2%-0.9%), respectively. Corresponding Pearl indices were 0.88 (95% CI, 0.44-1.33) and 0.7 (95% CI, 0.31-1.10). Contraceptive failure among women with a body weight < 90 kg (<198 lb) was low and uniformly distributed across the weight range. A subgroup of women with body weight > or = 90 kg (> or = 198 lb) may have increased risk of pregnancy. The incidence of breakthrough bleeding was low and decreased over time.

CONCLUSION(S)

In contraceptive patch users, the overall annual probability of pregnancy was 0.8% and the method failure probability was 0.6%. The efficacy of the patch was high and similar across age and racial groups. Among women < 90 kg (<198 lb), contraceptive failure was low and uniformly distributed across the range of body weights. In women > or = 90 kg (> or = 198 lb), contraceptive failures may be increased. Efficacy and cycle control have been shown to be comparable to an established oral contraceptive.

Absorption kinetics of misoprostol with oral or vaginal administration

OBJECTIVE

To compare the pharmacokinetics of vaginal and oral administration of the prostaglandin E1 analogue, misoprostol.

METHODS

Twenty women received 400-micrograms doses of misoprostol either orally or as tablets placed in the vagina. Serum levels of principal metabolite, misoprostol acid, were measured at 7.5, 15, 30, 45, 60, 90, 120, and 240 minutes. The first ten women were pregnant and undergoing first-trimester abortions, and the last ten were not pregnant and had additional blood sampling at 360 minutes. We compared the pharmacokinetics of misoprostol acid after oral and vaginal administration.

RESULTS

All 20 subjects completed the study. The maximum mean (+/- standard deviation [SD]) of misoprostol acid differed significantly between the oral and vaginal groups (277 +/- 124 compared with 165 +/d- 86 pg/mL, respectively; P = .03, analysis of variance), as did the mean +/- SD time to peak levels (34 +/- 17 compared with 80 +/- 27 minutes, respectively; P < .001) and areas under the misoprostol concentration versus time curve (mean +/- SD) up to 4 hours (n = 20,273.3 +/- 110.0 compared with 503.3 +/- 296.7 pg.hour/mL, respectively; P = .033) and up to 6 hours (n = 10, 300.0 +/- 103.3 compared with 956.7 +/- 541.7 pg.hour/mL, respectively; P = .029). The extent of absorption was highly variable among subjects in each group.

CONCLUSION

There are significant differences in the pharmacokinetics of misoprostol administered by vaginal and oral routes that may explain the difference observed in clinical efficacy. Assuming that the pharmacologic effect of misoprostol is related to its concentration in the plasma, our observation of the prolonged serum concentrations in the vaginal group suggests that vaginal administration could be dosed at longer intervals than oral.