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Clinics in Perinatology Sep 2016The physiology of the fetus is fundamentally different from the neonate, with both structural and functional distinctions. The fetus is well-adapted to the relatively... (Review)
Review
The physiology of the fetus is fundamentally different from the neonate, with both structural and functional distinctions. The fetus is well-adapted to the relatively hypoxemic intrauterine environment. The transition from intrauterine to extrauterine life requires rapid, complex, and well-orchestrated steps to ensure neonatal survival. This article explains the intrauterine physiology that allows the fetus to survive and then reviews the physiologic changes that occur during the transition to extrauterine life. Asphyxia fundamentally alters the physiology of transition and necessitates a thoughtful approach in the management of affected neonates.
Topics: Adaptation, Physiological; Ductus Arteriosus; Female; Fetus; Foramen Ovale; Heart; Humans; Infant, Newborn; Lung; Parturition; Pregnancy; Pulmonary Circulation
PubMed: 27524443
DOI: 10.1016/j.clp.2016.04.001 -
Mayo Clinic Proceedings Jun 2016Emergency contraception (EC) may help prevent pregnancy in various circumstances, such as contraceptive method failure, unprotected sexual intercourse, or sexual... (Review)
Review
Emergency contraception (EC) may help prevent pregnancy in various circumstances, such as contraceptive method failure, unprotected sexual intercourse, or sexual assault, yet it remains underused. There are 4 approved EC options in the United States. Although ulipristal acetate requires a provider's prescription, oral levonorgestrel (LNG) is available over the counter for women of all ages. The most effective method of EC is the copper intrauterine device, which can be left in place for up to 10 years for efficacious, cost-effective, hormone-free, and convenient long-term primary contraception. Ulipristal acetate tends to be more efficacious in pregnancy prevention than is LNG, especially when taken later than 72 hours postcoitus. The mechanism of action of oral EC is delay of ovulation, and current evidence reveals that it is ineffective postovulation. Women who weigh more than 75 kg or have a body mass index greater than 25 kg/m(2) may have a higher risk of unintended pregnancy when using oral LNG EC; therefore, ulipristal acetate or copper intrauterine devices are preferable in this setting. Providers are often unaware of the range of EC options or are unsure of how to counsel patients regarding the access and use of EC. This article critically reviews current EC literature, summarizes recommendations, and provides guidance for counseling women about EC. Useful tips for health care providers are provided, with a focus on special populations, including breast-feeding women and those transitioning to long-term contraception after EC use. When treating women of reproductive age, clinicians should be prepared to counsel them about EC options, provide EC appropriately, and, if needed, refer for EC in a timely manner.
Topics: Administration, Oral; Attitude of Health Personnel; Body Mass Index; Breast Feeding; Contraception, Postcoital; Contraceptive Agents, Female; Contraceptives, Postcoital; Female; Health Knowledge, Attitudes, Practice; Humans; Intrauterine Devices, Copper; Levonorgestrel; Nonprescription Drugs; Norpregnadienes; Ovulation; Patient Education as Topic; Pregnancy; Prescription Drugs
PubMed: 27261868
DOI: 10.1016/j.mayocp.2016.02.018 -
International Journal of Women's Health 2019Intrauterine adhesions with symptoms like hypomenorrhea or infertility are known under the term Asherman's syndrome. Although the syndrome has been widely investigated,... (Review)
Review
Intrauterine adhesions with symptoms like hypomenorrhea or infertility are known under the term Asherman's syndrome. Although the syndrome has been widely investigated, evidence of both prevention of the syndrome and the ideal treatment are missing. Understanding the pathogenesis of intrauterine adherences is necessary for the prevention of the formation of intrauterine scarring. Intrauterine adhesions can develop from lesion of the basal layer of the endometrium caused by curettage of the newly pregnant uterus. The syndrome may also occur after hysteroscopic surgery, uterine artery embolization or uterine tuberculosis. For initial diagnosis the less invasive contrast sonohysterography or hysterosalpingography is useful. The final diagnosis is based on hysteroscopy. Magnetic resonance imaging is required in cases with totally obliterated uterine cavity. Intrauterine adherences are classified in accordance with different classification systems based on the hysteroscopic diagnosis of severity and localization of adherences. Classification is necessary for the planning of surgery, information on prognosis and scientific purposes. Surgery is performed in symptomatic patients with either infertility or with painful periods. Intrauterine adherences are divided with a hysteroscope using scissors or a power instrument working from the central part of the uterus to the periphery. Peroperative ultrasonography is useful in an outpatient setting for the prevention of complications. Hysteroscopy with fluoroscopy is a solution in difficult cases. Use of intrauterine devices like balloon catheters or intrauterine contraceptive devices seems to be the preferred methods for the prevention of re-occurrence of adhesions after treatment. Both primary prevention after hysteroscopic surgery or curettage and secondary prevention of new adhesions after adhesiolysis have been investigated. The aim of this review was to summarize the literature on diagnosis, classification, treatment and prevention, based on a literature search with a wide range of search terms.
PubMed: 30936754
DOI: 10.2147/IJWH.S165474 -
American Journal of Obstetrics and... Aug 2020To provide updated and more detailed pooled intrauterine device expulsion rates and expulsion risk estimates among women with postpartum intrauterine device placement by... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
To provide updated and more detailed pooled intrauterine device expulsion rates and expulsion risk estimates among women with postpartum intrauterine device placement by timing of insertion, delivery type, and intrauterine device type to inform current intrauterine device insertion practices in the United States.
DATA SOURCES
We searched PubMed, Cochrane Library, and ClinicalTrials.gov through June 2019.
STUDY ELIGIBILITY CRITERIA
We included all studies, of any study design, that examined postpartum placement of Copper T380A (copper) or levonorgestrel-containing intrauterine devices that reported counts of expulsion.
STUDY APPRAISAL AND SYNTHESIS METHODS
We evaluated intrauterine device expulsion among women receiving postpartum intrauterine devices in the "immediate" (within 10 minutes), "early inpatient" (>10 minutes to <72 hours), "early outpatient" (72 hours to <4 weeks), and interval (≥4 weeks) time periods after delivery. We assessed study quality using the US Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of partial and complete intrauterine device expulsion separately and estimated adjusted relative risks by the timing of postpartum placement, delivery type, and intrauterine device type using log-binomial multivariable regression.
RESULTS
We identified 48 level I to II-3 studies of poor to good quality that reported a total of 7661 intrauterine device placements. Complete intrauterine device expulsion rates varied by timing of placement as follows: 10.2% (range, 0.0-26.7) for immediate; 13.2% (3.5-46.7) for early inpatient; 0% for early outpatient; and 1.8% (0.0-4.8) for interval placements. Complete intrauterine device expulsion rates also varied by delivery type: 14.8% (range, 4.8-43.1) for vaginal and 3.8% (0.0-21.1) for cesarean deliveries. Among immediate postpartum vaginal placements, the expulsion rate for levonorgetrel intrauterine devices was 27.4% (range, 18.8-45.2) and 12.4% (4.8-43.1) for copper intrauterine devices. Compared with interval placement, immediate and early postpartum placements (inpatient and outpatient combined) were associated with greater risk of complete expulsion (adjusted risk ratio, 8.33; 95% confidence interval, 4.32-16.08, and adjusted risk ratio, 5.27; 95% confidence interval, 2.56-10.85, respectively). Among immediate postpartum placements, risk of expulsion was greater for placement after vaginal compared with cesarean deliveries (adjusted risk ratio, 4.57; 95% confidence interval, 3.49-5.99). Among immediate placements at the time of vaginal delivery, levonorgestrel intrauterine devices were associated with a greater risk of expulsion compared with copper intrauterine devices (adjusted risk ratio, 1.90; 95% confidence interval, 1.36-2.65).
CONCLUSION
Although intrauterine device expulsion rates vary by timing of placement, type, and mode of delivery, intrauterine device insertion can take place at any time. Understanding the risk of intrauterine device expulsion at each time period will enable women to make an informed choice about when to initiate use of an intrauterine device in the postpartum period based on their own goals and preferences.
Topics: Delivery, Obstetric; Female; Humans; Intrauterine Device Expulsion; Intrauterine Devices; Postpartum Period; Pregnancy; Risk Factors; Time Factors
PubMed: 32142826
DOI: 10.1016/j.ajog.2020.02.045 -
American Journal of Obstetrics and... Dec 2022The 52-mg levonorgestrel-releasing intrauterine system is an established, long-acting contraceptive option with approved use for up to 7 years.
BACKGROUND
The 52-mg levonorgestrel-releasing intrauterine system is an established, long-acting contraceptive option with approved use for up to 7 years.
OBJECTIVE
The Mirena Extension Trial evaluated the efficacy and safety of the 52-mg levonorgestrel-releasing intrauterine system during extended use beyond 5 and up to 8 years.
STUDY DESIGN
This was a multicenter, single-arm study in the United States, enrolling existing users of the 52-mg levonorgestrel-releasing intrauterine system, aged 18 to 35 years, who have had the system for 4.5 to 5 years. We assessed the contraceptive efficacy (Pearl Index) and cumulative failure rate (using the Kaplan-Meier method) of the 52-mg levonorgestrel-releasing intrauterine system during extended use. We also evaluated bleeding outcomes and adverse events.
RESULTS
Of the 362 participants starting year 6, 243 entered and 223 completed 8 years of 52-mg levonorgestrel-releasing intrauterine system use. Just more than half the participants were parous. The mean (standard deviation) age was 29.2 (±2.9) years, and all participants were aged ≤36 years at the end of year 8. Two pregnancies occurred, both with the device in situ. The year 6 pregnancy was of undetermined location and resolved spontaneously. The pregnancy in year 7 was ectopic and resolved with methotrexate treatment. In both cases, the 52-mg levonorgestrel-releasing intrauterine system was removed and the participants left the trial. For years 6 to 8, the 3-year Pearl Index (95% confidence interval) was 0.28 (0.03-1.00) with a 3-year cumulative failure rate of 0.68% (0.17-2.71). Pearl Indexes for years 6, 7, and 8 were 0.34 (0.01-1.88), 0.40 (0.01-2.25), and 0.00 (0.00-1.90), respectively. The 3-year (years 6-8) ectopic pregnancy Pearl Index was 0.14 (0.00-0.77). We found treatment-emergent adverse events in 249 of 362 participants (68.8%), with 65 (18.0%) events considered to be related to the 52-mg levonorgestrel-releasing intrauterine system. The discontinuation rate was 38.4% (139/362), most commonly because of desire for pregnancy (12.2%, 44/362). During extended use beyond 5 years and up to 8 years, participants reported a decrease in the mean number of bleeding or spotting days with approximately half of the women experiencing amenorrhea or infrequent bleeding. We did not enroll a sufficient number of women using the 52-mg levonorgestrel-releasing intrauterine system for contraception and heavy menstrual bleeding to assess extended use for that indication. At the end of year 8, most (98.7%, 220/223) of the participants who completed the study remained satisfied with the continued use of the 52-mg levonorgestrel-releasing intrauterine system. Of the 31 women who discontinued early because of desire for pregnancy with evaluable data for return-to-fertility analysis, 24 reported a posttreatment pregnancy within 1 year, giving a 12-month return-to-fertility rate of 77.4%.
CONCLUSION
The 52-mg levonorgestrel-releasing intrauterine system, initially approved for 5 years, maintains high contraceptive efficacy, user satisfaction, and a favorable safety profile through 8 years of use. Participants reported 26 posttreatment pregnancies in total, of which 24 occurred in women who had discontinued the 52-mg levonorgestrel-releasing intrauterine system because of a desire for pregnancy. Of note, among women who elected to continue use through 8 years, bleeding patterns remained highly favorable. These findings support continued 52-mg levonorgestrel-releasing intrauterine system use for up to 8 years in women who wish to continue treatment.
Topics: Pregnancy; Female; Humans; Levonorgestrel; Intrauterine Devices, Medicated; Contraceptive Agents, Female; Menorrhagia; Metrorrhagia
PubMed: 36096186
DOI: 10.1016/j.ajog.2022.09.007 -
Obstetrics and Gynecology Dec 2022To explore to what extent intrauterine device (IUD) expulsion is associated with demographic and clinical risk factors. (Clinical Trial)
Clinical Trial
OBJECTIVE
To explore to what extent intrauterine device (IUD) expulsion is associated with demographic and clinical risk factors.
METHODS
The APEX-IUD (Association of Perforation and Expulsion of IntraUterine Devices) study was a U.S. cohort study using electronic health records from three integrated health care systems (Kaiser Permanente Northern California, Southern California, and Washington) and a health care information exchange (Regenstrief Institute). These analyses included individuals aged 50 years or younger with IUD insertions from 2001 to 2018. Intrauterine device expulsion cumulative incidence and incidence rates were estimated. Using Cox regression models, hazard ratios with 95% CIs were estimated before and after adjustment for risk factors of interest (age, race and ethnicity, parity, body mass index [BMI], heavy menstrual bleeding, and dysmenorrhea) and potential confounders.
RESULTS
In total, 228,834 individuals with IUD insertion and no delivery in the previous 52 weeks were identified (184,733 [80.7%] with levonorgestrel-releasing intrauterine system). Diagnosis of heavy menstrual bleeding-particularly a diagnosis in both recent and past periods-was the strongest risk factor for IUD expulsion. Categories with the highest risk of IUD expulsion within each risk factor included individuals diagnosed with overweight, obesity, and morbid obesity; those in younger age groups, especially among those aged 24 years or younger; and in those with parity of four or more. Non-Hispanic White individuals had the lowest incidence and risk, and after adjustment, Asian or Pacific Islander individuals had the highest risk. Dysmenorrhea was not independently associated with expulsion risk when adjusting for heavy menstrual bleeding.
CONCLUSION
Most risk factors for expulsion identified in this study appear consistent with known physiologic factors that affect uterine anatomy and physiology (age, BMI, heavy menstrual bleeding, parity). The increased risk of IUD expulsion among individuals of color warrants further investigation. Intrauterine devices are an effective long-term contraceptive; expulsion is uncommon, but patients should be counseled accordingly.
FUNDING SOURCE
Bayer AG.
CLINICAL TRIAL REGISTRATION
EU PAS register, EUPAS33461.
Topics: Female; Humans; Pregnancy; Cohort Studies; Demography; Dysmenorrhea; Intrauterine Device Expulsion; Intrauterine Devices; Intrauterine Devices, Copper; Intrauterine Devices, Medicated; Levonorgestrel; Menorrhagia; Risk Factors
PubMed: 36357958
DOI: 10.1097/AOG.0000000000005000 -
Deutsches Arzteblatt International Sep 2012The past decade has seen much progress in intrauterine surgery. Randomized trials have documented the benefit of some procedures of this type for the unborn child. (Review)
Review
BACKGROUND
The past decade has seen much progress in intrauterine surgery. Randomized trials have documented the benefit of some procedures of this type for the unborn child.
METHOD
Selective literature review
RESULTS
Randomized trials have demonstrated the benefit of fetoscopic laser coagulation of placental anastomoses in twin-to-twin transfusion syndrome (TTTS) and of intrauterine surgery via hysterotomy for the repair of spina bifida. Other fetoscopic procedures have yielded promising initial results but are not yet supported by findings from randomized trials. Some intrauterine surgical procedures must still be considered experimental in view of the lack of randomized trials and the rarity of the conditions they are designed to treat. Fetoscopic laser coagulation for TTTS is by far the most common procedure in fetal surgery; TTTS arises in roughly 1 in 2500 pregnancies. The other procedures discussed in this article are performed much less often and for rarer indications. In general, intrauterine surgery is indicated only to treat conditions that would otherwise lead to intrauterine death or irreversible prenatal damage.
CONCLUSION
Intrauterine surgery is a rapidly developing field. Prenatal intervention by laser coagulation is indicated to treat severe TTTS, as its benefit has been shown in a randomized trial. Not enough evidence is yet available for the possible benefit of intrauterine surgery to treat myelomeningocele and congenital diaphragmatic hernia. Other indications are experimental. When an indication for intrauterine surgery exists, the parents should be informed and, depending on their wishes, referred to a center where it can be performed.
Topics: Congenital Abnormalities; Female; Fetal Diseases; Fetofetal Transfusion; Fetoscopy; Humans; Hysterotomy; Infant, Newborn; Laser Coagulation; Pregnancy; Spinal Dysraphism
PubMed: 23093990
DOI: 10.3238/arztebl.2012.0603 -
Nursing Standard (Royal College of... Oct 2014Essential facts Intrauterine contraception (IUC) methods are long-acting reversible contraceptives with licensed durations of use lasting between three and ten years....
Essential facts Intrauterine contraception (IUC) methods are long-acting reversible contraceptives with licensed durations of use lasting between three and ten years. They include copper intrauterine devices (Cu-IUD), which are non-hormonal, and levonorgestrel intrauterine systems (LNG-IUS), which release levonorgestrel. They are suitable for most women, including those who have not been pregnant.
Topics: Contraindications; Education, Nursing, Continuing; Female; Humans; Intrauterine Devices; Intrauterine Devices, Copper; Levonorgestrel; Pregnancy; United Kingdom
PubMed: 25315545
DOI: 10.7748/ns.29.7.19.s24 -
Trends in Neurosciences Jun 2019The intrauterine environment provides a key interface between the mother and the developing fetus during pregnancy, and is a target for investigating mechanisms of fetal... (Review)
Review
The intrauterine environment provides a key interface between the mother and the developing fetus during pregnancy, and is a target for investigating mechanisms of fetal programming. Studies have demonstrated an association between prenatal stress and neurodevelopmental disorders. The role of the intrauterine environment in mediating this effect is still being elucidated. In this review, we discuss emerging preclinical and clinical evidence suggesting the existence of microbial communities in utero. We also outline possible mechanisms of bacterial translocation to the intrauterine environment and immune responses to the presence of microbes or microbial components. Lastly, we overview the effects of intrauterine inflammation on neurodevelopment. We hypothesize that maternal gestational stress leads to disruptions in the maternal oral, gut, and vaginal microbiome that may lead to the translocation of bacteria to the intrauterine environment, eliciting an inflammatory response and resulting in deficits in neurodevelopment.
Topics: Animals; Female; Fetal Development; Humans; Microbiota; Neurodevelopmental Disorders; Pregnancy; Uterus
PubMed: 31053242
DOI: 10.1016/j.tins.2019.03.008 -
Current Pathobiology Reports 2018Significant research reveals that the microbiome modulates perinatal and postnatal health. This review aims to examine mechanisms by which intrauterine infection, the... (Review)
Review
PURPOSE OF REVIEW
Significant research reveals that the microbiome modulates perinatal and postnatal health. This review aims to examine mechanisms by which intrauterine infection, the epigenome, and microbiome specifically influence preterm infant health outcomes.
RECENT FINDINGS
Intrauterine infection is a primary cause of preterm birth and can cause alterations in gene expression and epigenetic programming as well as postnatal inflammatory responses in the offspring. Insights from our own studies demonstrate epigenetic modifications of TLRs associated with exposure to intrauterine inflammation, as well as a cross talk between host epigenome and microbiome. Lastly, the gut microbiome modulates maturation of inflammatory pathways, which influences the development of preterm infants.
SUMMARY
We present a unifying theme that preterm infant outcomes are associated with modulation of host immune and inflammatory responses, which are influenced by acute intrauterine infection, epigenetic, and microbiome factors.
PubMed: 29938128
DOI: 10.1007/s40139-018-0159-9