COMMUNICATIONS IN BRIEF
This section is suitable for reporting cases, results of therapeutic trials, and descriptions of new procedures or instruments. Reports should be iimited to seven hundred words and two references. Use of an illustration or table requires a proportionate reduction in total words.
The
Dalkon
Shield
in
private
pain after insertion were less of a problem with this new device. To date, no expulsions at all have occurred with the shields. However, the recurrent problem of unwelcome pregnancies stimulated a tabulation of the personal experiences of patients with all types of intrauterine devices in my private practice. The accumulated woman months of experience with each type of IUD and the events observed with each group of patients are recorded in Table I. The expulsions were most common among the loop-A group, and all that occurred were in patients with loops, but removals due to pain, bleeding, inflammatory disease, and patient concern were necessary in about 10 per cent of all patients. The only perforation in the series, which was with a large shield, probably represents partial perforation at the time of insertion. The results with the loop are consistent with the expected pregnancy rate as described by Lippes.1 The 10 per cent pregnancy rate with the shield, however, was not expected. The months after insertion, during which pregnancies, removals, and expulsions occurred, are recorded in Table II. In this private practice, the loop intrauterine contraceptive device has demonstrated the expected 97 per cent protection from pregnancy. The expulsion rate is quite high compared to that for the shield. With nulliparous patients, the combined removals for bleeding and pain and the expulsion rates exceeded 50 per cent and indicate a continuing need for research and development of intrauterine contraception for these patients. The high pregnancy rate associated with the shield makes its continued use unacceptable. Some patients with the shield have elected to keep the device and use contraceptive foam during the fertile time of their cycle. Review of the article which recommended the shield and claimed a 98.9 per cent efficacy for it reveals no data which support the 1.1 per cent pregnancy rate.” Neither the number of patients involved nor the dura-
practice:
A disappointment ROBERT Department
L.
M.D.
of Obstetrics and Gynecology, School, The Boston Hospital and the Peter Bent Brigham Hospital, Massachusetts
Harvard Medical Women, Boston,
SHIRLEY,
for
D u RI N G T 11 E first two years of a one-man, university hospital-based, private practice, most patients interested in birth control asked for and did well with oral contraceptives. During the summer of 1970, a number of trends seemed evident. The Nelson Committee had influenced patients to request a change from oral to intrauterine methods of contraception. Both my patients and I were impressed by testimony from a usually thoughtful and trustworthy university which indicated that the new Dalkon Shield represented a real improvement in effectiveness and patient acceptability. During the same period of time, difficulties appeared with the use of the A Lippes Loop in nulligravid patients. Less than half of the A-loop insertions resulted in effective birth control. One pregnancy with the loop in place and 2 pregnancies after unrecognized expulsions had further dampened enthusiasm for this device in nulligravid patients. As a consequence of these factors, in June of 1971, the insertion of loops was essentially discontinued, and in their stead, shields were inserted. After the first few insertions, the technique seemed mastered, with devices seated well into the fundal region with the thread and knot in proper position. A posterior cervical injection of 2 ml. of local anesthetic made the insertion much more comfortable for many patients. It seemed clear that vasovagal reactions and cramping Reprint requests: Dr. Robert L. Shirley, Barton Shirley, Inc., Obstetrics and Gynecology, Brook House, Suite 9, 33 Pond Ave., Brookline, Massachusetts 02146.
564
Volume 121 Number 4
Table
Communications
I.
Summary
169 patients
of woman
since
October,
months
pregnancy
experience,*
percentage,
and
pregnancies
Loop
total
and Saf “T”
Small Large
Coil
shield shield
Shield
total
*Pregnancies,
Cumulative woman months
No. of patients
Type of IUD “T” Coil (small) A B c D
Loop
expulsions,
Pregnancies with IUD
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
0 1 0 1 0
0 4 0 1 2
57
901
2
7
59
959
2
7
57 53
574 655
4 7
0 0
110
1,229
or removals
for
11 bleeding,
pain,
tion of the to be viewed
PP P r
Large 1 shield1
Loop A
rrr Prrx
rr
PP
r Pxx
1
Loop B
1
r
Loop C
Loop 1 D
X
x
in
13 (23)
3.5
2.7
13 (22)
3.4
2.5
6.9 13.2
8.3 12.8
10
10.7
11 (10)
gonococcal
MALCOLM
amnionitis
J. ROTHBARD,
M.D.
GREGORY, J.
SALERNO,
Department of Obstetrics Medical College, Flower New York, New York
M.D. M.D. and and
Gynecology, New York Fifth Avenue Hospitals,
increasing incidence.1 Pregnancy does not confer any unusual protection against acute gonorrhea.’ All patients should be screened for gonorrhea as well as syphilis not only at the first prenatal visit but also at periodic intervals until term. The following case report illustrates a complication of asymptomatic gonorrhea during pregnancy.
r x
r r
follow-up was with suspicion
0 5.5 0 5.7 0
per years
reaction.
Intrapartum
LOUIS
Pregnancies 100 woman
0 6.7 0 8.3 0
(53) (13) ( 8) (14)
8 (14) 3 ( 6)
0 cr inflammatory
Pregnancy percentage
T n E F a E (2 u E N T L y asymptomatic nature of gonorrhea in women is one of the most important causes for its
r
The number small. Certainly of such a small raw data and enough so that shield contraception
years
x r
P
P
0 8 1 1 3
THOMAS
IUD
Prr P P
woman
other
Totals (%)
Expulsions
58 217 171 254 259
I “ziie!t;‘,,“”
in
2 15 8 12 22
Table II. The temporal occurrence of pregnancies (P), removals for symptoms (r), and expulsions (x) for the various IUD’s in 169 patients
Small 1 shield
100
565
1968 Expulsions and removals
Saf Loop Loop Loop Loop
per
in brief
provided. This at this time.
conclusion
has
of patients included in this report is life table analysis and statistical analysis group seem inappropriate. However, the crude pregnancy rates are impressive no more patients will be provided with alone.
The patient was a 20-year-old black primipara, whose last menstrual period was uncertain, possibly June, 1973. At the first prenatal visit on October 5, 1973, a routine culture of vaginal secretions on Thayer-Martin medium was positive for Neisseria gonorrhoeae. She was treated with 4.8 million units of aqueous penicillin intramuscularly. HOWever, the patient was delinquent and did not return for reculture for a “test of cure” at one week. She returned to the prenatal clinic on January 31, 1974, and culture was repeated because of persistent leukorrhea. Before the report was returned, however, the patient was admitted to the hospital on February 3, 1974, because the membranes ruptured 36 hours previously and she had mild irregular contractions for 6 hours. On admission, examination revealed a well-developed
REFERENCES
1. 2.
Lippes, J.: AM. J. OBSTET. Davis, H. J., and Lesinski, 350, 1970.
GYNECOL.
J.:
Obstet.
93:
1024, Gynecol.
1965. 36:
Reprint Obstetrics tals, 1249
requests: Dr. Louis J. Salerno, Department of and Gynecology, Flower and Fifth Ave. HospiFifth Ave., New York, New York 10029.