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Postcoital contraception (PC) has become more effective in recent years and is recommended for women who have had unprotected coitus between the 8th and 17th days of their cycles. Vaginal douche using a spermicide solution is ineffective as it has resulted in a 37% pregnancy rate. Estrogens are far more effective: Diethylstilbestrol (DES), taken in doses of 25-50 mg daily for 5 days, e.g., 10 mg of conjugated estrogens 3 times daily, and 2.5 mg ethinyl estradiol 2 times daily for 5 days 24-72 hours after coitus, has resulted in a .5-1.5% pregnancy rate. Side effects, however, include nausea, vomiting, mastalgia, menorrhagia, extrauterine pregnancy, and adenocarcinoma in daughters of DES-treated women. Gestagens, such as .15-.40 mg of d-norgestrel taken 3 hours after coitus, can be used as a form of planned PC. In an experiment, an estrogen-gestagen preparation consisting of 50 mcg ethinyl estradiol and 500 mcg dl-norgestrel taken 12-72 hours after coitus produced a .9% pregnancy rate in 1300 menstrual cycles with few serious side effects. Copper 7 or copper-T IUDs also prevent the implantation of the fertilized egg, and, when used within 5 days after coitus, produced only 1 pregnancy in 727 cases. The ideal future PC would be a preparation that inhibits either ovulation or nidation and has limited side effects. Among some promising agents are a luteinizing hormone-releasing factor agonist as well as natural and synthetic prostaglandins; however, until their cardiovascular and gastrointestinal side effects have been ameliorated, their routine use is unlikely.
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PMID:[Postcoital contraception]. 661 4

A case is presented of a 29-year old woman who developed sudden onset of abdominal pain, vomiting, near syncope, abdominal tenderness, profound hypotension, and a late menstrual period. The patient was in good health and her only medication was zomepirac for musculoskeletal discomfort. An exploratory mini-laparotomy was performed for the suspicion of a ruptured ectopic pregnancy, but no evidence of hemoperitoneum or of ectopic pregnancy was found. A subsequent pregnancy test was negative, and the episode was attributed to a zomepirac reaction. A review of zomepirac and zomepirac reactions is included.
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PMID:A zomepirac reaction mimicking ectopic pregnancy. 673 36

RU 486, a new antiprogestational compound, was given to 37 women seeking termination of pregnancy and with amenorrhea of 42 days or less. 1 patient was found at the 2nd follow-up visit to have an extrauterine pregnancy. The patients received either 25 mg, 50 mg, or 100 mg RU 486 twice daily for 4 days. All patients attended 3 follow-up visits, 1, 2, and 5-6 weeks after the start of therapy. The start, duration, and amount of bleeding as well as plasma progesterone, beta-human chorionic gonadotropin (hCG) and cortisol concentrations were determined for each treatment day and at follow-up visits. All but 3 patients started to bleed during treatment. Frequency of complete abortion was 61% (22 of 36 patients). In only 3 patients was the pregnancy unaffected by treatment. The clinical efficacy of the treatment was not dose-dependent. Most of the patients experienced only minor dise effects in terms of mild uterine pain, nausea, and vomiting. However, 2 patients suffered from heavy bleeding requiring blood transfusion and curettage. In patients with complete abortion, beta-hCG values decreased significantly but not until the 1ft follow-up visit. The plasma progesterone also decreased. This decrease appeared earlier with the higher daily dose of RU 486. Cortisol concentrations increased during treatment with all 3 dosage regimens but the levels remained within the normal range. It is concluded the treatment with RU 486 may provide a novel therapy for menstrual regulation but the efficacy of it needs to be improved to compete with such alternatives as vacuum aspiration.
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PMID:Termination of very early pregnancy by RU 486--an antiprogestational compound. 674 60

Some form of postcoital contraception for protection against unwanted pregnancy is indispensable today especially in cases of rape, failed mechanical contraception, or 1st sexual contact without contraception. A tabletform of postcoital contraceptive would be acceptable if 100% certainty is assured and it doesn't involve adverse effects. Postcoitally administered high-dose estrogens proved effective in Macaca mulatta. Diethylstilbestrol in variable dosages with or without ethinylestradiol was used in various studies and with variable results. Pregnancy rates depended on time of coitus in cycle, contraceptive dosage, and time of administration after coitus (within 72 hours). Conjugated estrogens and various progestagens or combinations of both have been tried with variable success. Another form of postcoital contraception is IUD insertion within 7 days following unprotected coitus. Advantages of this method are the time factors and absence of adverse effects of hormonal contraceptives. Postcoital hormonal contraceptives cause changes in the endometrium which prevent blastocyst implantation. They alter tubal function affecting zygote movement towards the uterus. They have an antiovulatory effect and may be luteolytic. Estrogens have more severe side effects than progestagens. Nausea, vomiting, mastodynia, fluid retention, and vaginal bleeding can result from estrogens. Progestagens can cause irregular bleeding. Combination of both can cause menstrual irregularity. Postcoital hormonal contraceptives are contraindicated in heart and liver diseases, thrombosis, and pregnancy (teratogenic and carcinogenic effects on offspring). Pregnancy despite postcoital contraception results in extrauterine pregnancy in 10% of patients. The most important reservations in evaluating publications on this subject are: 1) lack of control group; 2) estimation of pregnancy probability is not reliable because of study population used; 3) patient fertility cannot be ascertained; and 4) reliability of information provided by patient. Conclusion from literature studies is that postcoital hormonal contraception is of value but effectiveness is not proven. More research is needed and indications are that other less radical drugs may be found in near future.
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PMID:[Postcoital contraception]. 725 97

This study analyzes the clinicopathologic findings in patients with ectopic pregnancy (EP), and deals with the differential diagnosis of the EP, intrauterine pregnancy (IUP), and pelvic inflammatory disease (PID). We evaluated 346 patients with suspected EP. Among those, 119 patients had EP, 82 had IUP, and 55 had PID without pregnancy. The incidence of EP was 1/32.9 live births. Comparing with the other groups, the patients with EP were slightly older, gave a history of previous pregnancies, had acute abdominal pain, nausea, vomiting, dizziness, and fainting, and had direct and rebound abdominal tenderness, pain on motion of the cervix, absence of a pelvic mass, and bilateral adnexal or cul de sac fullness. Culdocentesis was accurate in 95.1% of EP cases. Salpingectomy was performed in 89.9% of the patients with EP. The patients with EP had gross evidence of PID at the surgery in 31% and microscopic evidence of tubal inflammation in 19.4% of cases.
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PMID:Ectopic pregnancy. A prospective study on differential diagnosis. 726 61

Side effects are an expected part of medical abortion; some, such as pain and bleeding, result from the abortion process itself and are generally managed with orally administered analgesics and counseling. True medication side effects most commonly include nausea, vomiting, diarrhea, and warmth or chills. Complications of medical abortion usually represent an extreme or severe side effect. Large series have reported transfusion rates of <1%. Because of the infrequency of uterine instrumentation, postabortal endometritis appears to be rare with medical abortion. As with early surgical abortion, the clinician must remain aware of the possibility for ectopic pregnancy. Overall approximately 2% to 10% of patients will require surgical intervention for control of bleeding, resolution of incomplete expulsion, or termination of a continuing pregnancy. Understanding the types of side effects and complications that can occur will enable the clinician to counsel patients properly as well as to understand when medical intervention is necessary during the medical abortion process.
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PMID:Management of side effects and complications in medical abortion. 1094 71

Ectopic pregnancy (EP) is a major cause of maternal morbidity and mortality. The treatment of this condition is primarily surgical, but medical management in selected cases is safe, effective, cost-effective and eliminates the morbidity of surgery. Methotrexate (MTX) is a folate antagonist that can be used for non-oncologic purposes including the treatment of EP. The dose and duration of MTX therapy for EP is much lower than that used in oncology cases, thus reducing side effects and increasing safety. MTX selectively acts on rapidly dividing cells, such as trophoblast cells which comprise the implantation site of the early gestation. The two most common methods of administering MTX to patients with EP are im. administration of a single-dose, based on body surface area and calculated by the equation 50 mg/m(2) (without the need for leucovorin rescue), or the multiple-dose regimen of 1 mg/kg of MTX, alternating with 0.1 mg/kg of leucovorin rescue. Both methods have a similar side effect profile, resulting in the rare occurrence of nausea, vomiting, stomatitis, elevated liver function tests, anorexia and diarrhoea. The two methods yield success rates similar to those of conservative surgical therapy with similar future fertility. The potential single- and multi-dose methods have never been directly compared, but it appears that the success of multiple dosing is more effective. As the efficacy of MTX therapy is not 100%, women must be followed clinically until there is compete resolution of human Chorionic Gonadotropin (hCG) titres from their serum.
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PMID:The pharmacology of methotrexate. 1133 95

3 conditions may be responsible for absence of menstruation in women taking the minipill: pregnancy, extrauterine pregnancy, or endometrial atrophy which is the most frequent cause but should be treated only after the other 2 possibilities are excluded. The most frequent cause of pregnancy while taking minipills is error in pill consumption due to forgetting, but malabsorption due to vomiting less than 2 hours after taking the pill or an interaction with some other medication may be responsible. The possibility of extrauterine pregnancy should be systematically considered, and the possibility that a micropill and not a minipill is involved should be ruled out. With a sequential minipill contraceptive efficacy does not reach 100% but iatrogenic amenorrhea is infrequent because of the strong dose of ethinyl estradiol. In the case of a preexisting amenorrhea that does not respond to the estrogen or progestin dose, a prolactin adenoma may be suspected. After 2 consecutive beta tests of pregnancy 8 days apart have been negative, it may be concluded that endometrial atrophy is the cause of the amenorrhea. Unprotected sexual relations should be avoided and the patient should be given a fast-acting combined oral contraceptive such as Lutestral to induce bleeding, after which the minipill can be resumed. If unprotected intercourse occurs there is a risk of pregnancy since amenorrhea and anovulation are not synonymous. A morning after pill can be used if the unprotected sexual relations occurred within the last 72 hours. If a pill was forgotten or probably forgotten before the emenorrhea, the most prudent attitude would be to consider the pill to have been ineffective during the preceding 21 days and to test for pregnancy. Unprotected intercourse should be avoided, a fast-acting combination pill should be prescribed to induce bleeding, and the minipill should then be resumed. Amenorrhea in the 1st month of use after an abortion is not significant. This secondary effect of the minipill should be explained to the patient to avoid unnecessary worry.
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PMID:[Do's and don'ts in treating amenorrhea in women taking the minipill]. 1226 2

Current interceptive methods of contraception utilizable between ovulation and nidation include hormonal methods and IUDs. Since the 1st clinical study of the use of high doses of estrogen as a postcoital contraceptive appeared in 1967, the remarkable efficacy of the method has been confirmed by numerous other studies. The most important series used 50 mg diethylstilbestrol (DES) or 5 mg ethinyl estradiol (EE) per day for 5 days beginning within 72 hours of unprotected intercourse. The mechanism by which estrogens exercise their interception are unclear, but there are probably several factors involved including luteolysis and anomalies in endometrial development. The method is highly effective but rates of nausea, vomiting, breast tenderness, and to a lesser degree menorrhagia are high. The incidence of extrauterine pregnancy is about 1 per 10 intrauterine pregnancies for any postcoital method. Estrogen postcoital contraception is preferable to DES because of the fear of genital adenosis or vaginal adenocarcinoma in case of failure of DES. Opinion is divided as to the teratogenic risks of high doses of estrogens in general. Postcoital contraception with a progestin, levonorgestrel, which renders the endometrium inhospitable to nidation, was 1st described in 1973. The efficacy of norgestrel alone depends on the dose used. The most common secondary effects are spotting and cycle shortening. The method has the advantage of requiring a very small dose, but the disadvantage of requiring administration in the 12 hours following intercourse. Several combinations of estrogens and progestins have been proposed for postcoital use, of which the most interesting consists of 1 mg of dl-norgestrel and 100 mcg of EE repeated exactly 12 hours later. The treatment should be administered within 12 hours of unprotected intercourse. A multicenter study of 692 women treated with this method gave a pregnancy rate of 1.6%, which would have been lower if 4 women not meeting the conditions of treatment had been excluded. 52.7% of women treated had nausea or vomiting. Compared to estrogens alone, the EE-Norgestrel combination takes less time, requires 4 pills instead of 50 or 60, is better tolerated overall, and requires much less estrogen. Postcoital insertion of an IUD is very effective and has the advantages that it can be used later than 72 hours following intercourse, it is the only method currently available in case OCs are contraindicated, it allows subsequent longterm effective contraception, and it is 100% effective. The major disadvantages are pain on periovulatory or postovulatory insertion and the risk of infection. Possible future hormonal methods of postcoital contraception based on use of anti-progesterone steroids, especially RU486, or of luteinizing hormone releasing hormone agonist are currently under development.
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PMID:[Post-coital contraception]. 1228 Feb 7

Lithopaedion (stone baby) is the name given to an extrauterine pregnancy that evolves to foetal death and calcification. There are around 300 cases reported in the world medical literature to date. We report the case of a 40-year-old woman who presented with features of acute intestinal obstruction (abdominal distention, vomiting and absolute constipation) for a week. She had a past history of a missed abortion in the fifth month of gestation, eight years prior to this presentation, one which we thought to be irrelevant to the present illness. However, complementary investigations, including scout abdominal radiographs and ultrasonography of the abdomen and pelvis, were done before the operation. The abdominal radiograph showed two opaque globular masses on either side of the lower abdomen with distended small intestinal loops. Exploratory laparotomy was performed and a portion of strangulated small bowel attached to a solid globular mass behind the left ovary was removed, with a subsequent resection of the gut and end-to-end anastomosis. Upon removal of a thick membrane from the globular mass, a dead five-month-old calcified foetus was recovered. In the right iliac fossa, a similar mass was removed and another dead calcified foetus of similar age was recovered.
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PMID:Twin lithopaedions: a rare entity. 1772 71


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