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Sustained-release progestin contraceptives are a new approach to meeting a worldwide need for more effective and acceptable birth control. These contraceptive systems provide low, stable levels of synthetic progestins for periods of months to several years. Unlike earlier injectable and oral contraceptives, they do not cause peaks in progestin levels beyond those required for effective contraception, nor do they employ estrogens. For these reasons, sustained-release progestin systems are without some of the health risks attributed to birth control pills, and they are more effective, as well as easy to use, and completely reversible. They share common side effects, the most frequent of which is irregular menstrual bleeding caused by the erratic shedding of hypotrophic endometrium. Despite this and other minor side effects, most users find the sustained-release systems acceptable alternatives to other methods of contraception. Permanent or biodegradable subdermal implants, injections, intrauterine and intracervical devices, and vaginal rings are all employed as delivery systems for contraceptive progestins. The Norplant (Wyeth Ayerst, Radnor, PA) system, consisting of six silastic tubes filled with levonorgestrel and implanted under the skin, was recently approved by the US Food and Drug Administration and is already used by more than a half million women worldwide. The other sustained-release systems are in various stages of development, at least several years away from general use. When these new methods complete clinical trials, women will be able to choose from among implants, injections, or pellets with various durations of action, all providing convenient, highly effective contraception with low risk to health.

Two hundred and five women participating in a five-year clinical trial of NORPLANT and NORPLANT-2 were interviewed about their contraceptive and reproductive history, sources of information and knowledge of NORPLANT, experiences using the method, and the impressions of friends and family about the method. The most common reasons for trying the implants were dissatisfaction with other methods and perceptions about NORPLANT's ease of use. Forty-one percent of acceptors had anxiety prior to insertion; 49 percent of these feared pain, but only 5 percent said that they actually experienced significant pain. Women also feared implant removal, but their fear did not influence their decision to continue or discontinue use, and 74 percent reported little or no pain at removal. Most of the women were pleased with NORPLANT, although 95 percent reported side effects, with 82 percent reporting changes in menstruation. More than one-half of those women who discontinued reported that they would use the implants again. Seventy-four percent of the current users interviewed said they would like to use the implants in the future. For the women enrolled in the clinical trial, NORPLANT appeared to be a highly acceptable method of contraception, despite the frequent occurrence of bothersome side effects.

Review of the records of 15 women who had uterine perforations at the time of second-trimester abortion by dilation and evacuation showed that unexpected pain (but not excessive bleeding) was the most prominent sign. All patients required laparotomy, but in no case was laparotomy necessary as an emergency procedure. Laparoscopy was not helpful. Two-thirds had bowel injuries and two required hysterectomy. Errors in estimating gestational duration, inadequate cervical dilation, and failure to use sonography characterized these complicated cases.

The majority (72 percent) of U.S. residency programs in obstetrics and gynecology include first-trimester abortion techniques in their training. Programs affiliated with public hospitals or with private non-Catholic institutions are the most likely to provide such training, while Catholic-affiliated training programs and those at military hospitals are the least likely to do so. Approximately 23 percent of institutions include abortion training as a routine part of residency, and 50 percent offer it as optional training. The 28 percent of residency programs that offer no abortion training represents an almost fourfold increase since 1976. Although more of the large programs affiliated with public hospitals now include such training as a routine part of their residency programs, fewer of the private non-Catholic programs--where the largest proportion of residents are trained--do so. Consequently, the number of residents exposed to abortion training may have declined slightly over the past decade. Little difference exists between the proportion of programs that offer training in first-trimester techniques and the proportion that train in second-trimester techniques. Nine percent of programs report that all residents participate in first-trimester abortion training, and another 56 percent report that at least half of their residents do so. The participation rate is linked to the expectations of the program: Approximately 88 percent of programs that routinely incorporate abortion techniques in their training report that from one-half to all their residents participate, compared with about 55 percent of programs that offer the training as an option. Approximately 82 percent of programs teach abortion techniques up to at least 20 weeks' gestation.(ABSTRACT TRUNCATED AT 250 WORDS)

We reviewed 5,003 records of consecutive deliveries in 1975 and 1976 at Boston Hospital for Women, abstracted demographic and obstetric data, and analyzed singleton deliveries at 27 weeks' gestation or greater. We compared women with exactly one prior proximate induced or spontaneous abortion with women of similar gravidity or parity with no prior pregnancy losses. Offspring of women with a proximate induced abortion had no higher frequency of short gestations, low Apgar scores, or congenital malformations than those born of women with no prior loss. Offspring of secundigravidas with a proximate abortion had birth weights similar to those of other primigravidas. Thus we have found that women with a single prior induced abortion have no increased risk of poor outcome of the next pregnancy after 27 weeks' gestation. In contrast, offspring of secundigravidas with a proximate spontaneous abortion had an increased frequency of short gestations, low birth weights, low Apgar scores, and congenital malformations, indicating that these women are a high-risk group for subsequent poor late pregnancy outcomes.

Oral contraceptives have not been associated with exacerbation of epilepsy despite warnings in package inserts. No clinical study has provided scientific evidence of worsening of seizures in epileptic women who use oral contraceptives, and improvement in seizure control has occurred in some cases. The main concern about use of oral contraceptives in this population is their effectiveness in preventing conception. Failure rates are higher in groups of women taking enzyme-inducing antiepileptic drugs. The degree of increased metabolism of estrogen and progestin components is highly variable and unpredictable among individuals. Use of higher doses increases protection against conception but also increases the risk of side effects, particularly in patients in whom no enzyme induction occurs. The strength of hormones in the pill should be selected individually when initiating use. Some women may require higher doses for full contraceptive effect.

Preoperative cervical dilation makes first-trimester abortion safer, but increases costs and inconvenience to patients if extra visits are required. Eighty-four pregnant primigravid volunteers who requested first-trimester abortion were assigned randomly to one of four study groups: placebo, 16 dimethyl prostaglandin E2 (PGE2) vaginal suppository, 4-mm hypan plastic dilator, or small Laminaria japonica tent. This grouping was done to determine which of three modalities is most effective for cervical dilation within three hours before abortion. After three to four hours of treatment, hypan achieved greater cervical dilation among primigravid women and only modestly increased side effects, as compared with 16 dimethyl PGE2 suppositories or laminaria tents.

A half million women die yearly around the world as a result of pregnancy. Many of these deaths are inaccurately classified and many others are not reported at all, but new demographic techniques have clarified causes of maternal mortality and improved estimates of rates. New data from several less developed countries suggest that many maternal deaths could be prevented by measures already demonstrated to be effective elsewhere. These include better antenatal and intrapartum care, contraception for women who want no more pregnancies, legal abortion to terminate unwanted pregnancies, and uterine aspiration and antibiotics for treatment of septic abortion.

Capronor, a single-capsule, biodegradable, subdermal contraceptive that releases levonorgestrel over a 12- to 18-month period, has been evaluated in 48 healthy women, ages 18 to 40 years. Sixteen participants received a 2.5 cm capsule (12 mg of levonorgestrel), and 32 received a 4.0 cm capsule (21.6 mg of levonorgestrel). Serum levonorgestrel levels were significantly lower in the 2.5 cm group. Ovulation occurred in all cycles in the 2.5 cm group and in 26.3% of cycles in the 4.0 cm group. Levonorgestrel levels with the shorter capsule were too low for reliable contraception in all users, and 4 cm may be a minimal functional length. Bleeding patterns were regular in most women who ovulated and irregular in most remaining subjects. It is assumed that changes in cervical mucus and the endometrium contributed to effective contraception despite the frequency of ovulation.

A case of massive exudative hemorrhagic ascites occurring as a serious complication of chronic pelvic inflammatory disease (PID) is presented. The clinical manifestations, simulating diffuse carcinomatosis in a young female patient, are described.

The use of laminaria has made possible safe uterine evacuation in the second-trimester and has been identified as a protective factor in the prevention of uterine perforation in first-trimester abortion. Two additional approaches to cervical dilation are now available - synthetic hydrophilic dilators and prostaglandin analogues. Neither has been in use long enough to undergo thorough evaluation, but it seems possible that they may confer similar advantages while avoiding the discomfort and inconvenience associated with laminaria. New approaches to the use of laminaria have increased their value as cervical dilators. They may be left in the cervix for 6-48 hours. Multiple sets may be employed to achieve adequate cervical dilation for late second-trimester uterine evacuation. When fetal membranes are intact, prolonged use or multiple insertions of laminaria do not appear to increase rates of post-abortion infection. Lamicel and Dilapan are new synthetic dilators which affect the cervix much more rapidly than laminaria. The former does not apply radial force to the walls of the cervical canal, but the latter does. Significant dilation may be achieved in a few hours. Prostaglandins can also alter the cervix in only a few hours. Meteneprost appears to do so with minimal gastrointestinal side-effects and with a low risk of bleeding or abortion.

Second trimester elective abortion is safest when accomplished with cervical dilation and instrumental uterine evacuation (D and E), but this procedure carries with it a risk of uterine perforation and possible intra-abdominal trauma. In order to determine if the routine use of intraoperative ultrasonography reduces the risk of this feared and serious complication, 353 elective abortions at 16 to 24 weeks gestation performed without sonography were compared to 457 in which sonography was routinely employed. All 810 operations were carried out in one clinic using the same operative technique. The routine intraoperative use of ultrasonographic imaging to guide intrauterine forceps during uterine evacuation for second trimester elective abortion resulted in a significant reduction in uterine perforation, the rate declining from 1.4% to .2%. These findings support the routine use of intraoperative ultrasonography for second trimester elective abortion to reduce the incidence of uterine perforation and make the procedure a safer one.

Two patients at 22 weeks' gestation underwent extensive cervical dilation with laminaria tents for elective abortion but continued their pregnancies instead. Both had normal deliveries. For the unusual patient who chooses not to carry out an abortion initiated with cervical dilation, successful pregnancy is possible and therapeutic intervention such as cervical cerclage seems inadvisable.

Under ultrasonographic guidance, a 5-cm, symptomatic submucous myoma was removed from the uterus during a second-trimester pregnancy termination. The procedure was rapid and well tolerated and suggests that intraoperative sonography may provide a transvaginal alternative to laparotomy in the treatment of submucous myomata.

To determine the seroprevalence of human immunodeficiency virus (HIV) in contracepting women, 1,308 consecutive attendees at an inner-city family planning clinic completed a risk factor questionnaire and were then asked to have an HIV test. None of the 1,000 women tested was seropositive. Preventive efforts in family planning clinics are likely to be productive because few contraceptors, including those with risk factors, are already infected. The factors which determine differences in HIV positivity between childbearing and contracepting women, who are similar in demographic and HIV risk characteristics, warrant further investigation.