Situation analysis

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vaginal ph. This results in a consequent loss in the protection of the urogenital tract to local infections. It is possible that the motor activity in the urinary tract is directly related to the action of estrogen in the target organs and/or the nervous system. In animals where the ovaries were surgically removed, the treatment with estrogen increased the contractility response to stimulation in the bladder and the urethra. This is probably the result of stimulation of the alpha adrenergic receptors. Therefore, estrogen and alpha adrenergic antagonists could be used as an experimental tratment for stress urinary incontinence in the post menopausal women. The low dose estrogens are ideal for the women with post menopausal stress incontinence. In this manner estrogen can be administered orally or vaginally in a way that would not produce post menopausal bleeding due to the endometrial stimulation. With estriol and eventually with low dose of estradiol, the effect is only local, that is only in the urogenital area. We can also recommend vaginal creams for prolonged periods or in short periods to improve the local tissues prior to reconstructive surgery.

RM1.03.04 SELECTION William USA

OF TREATMENT Eastern Virginia Medical School, Norfolk, VA,

This lecture will present options for trating menopausal symptoms and for reduction of diseases of advancing age. The first and most omportant of the options is lifestyle changes that improve health such as cessation of smoking, moderation of alcohol consumption, and control of weight. Hormone replacement therapy (estrogen or estrogen/progestin) is the modality having the greatest potential of meeting both the objectives of treatment and prevention. Different regiments of dosage will be discussed as well as the advantages and disadvantages of the various delivery systems and schedules of administration. The choice is influenced by the age of the patient, family history, physical condition, as well as individual preference and should be tailored to the needs of each woman. The reasons for the addition of androgen to hormone replacement therapy will be discussed as well as the use of Tiolone. For women for whom hormonal replacement therapy is contraindicated or not desired, other options are available such as bisphosphonates or SERMS for bone health or statins for coronary artery disease prevention. The increasing interest of women in alternatives such as nutritional supplements will b mentioned as well as the limited data available about their efficacy.

RM1.04.01 FIRST TRIMESTER ABORTION WITH RU 486 M. Bvndeman, K. Gemzell Danielson, L. Marions, Karolinska Stockholm, Sweden

Hospital,

A medical method for termination of early pregnancy has for long been aimed at. Prostaglandin analogues were effective but side effects limited their clinical usefulness. The development of antiprogestins, compounds which interfere with progesterone at the receptor level, offered a new possibility. However, it was only when demonstrated that treatment with antiprogestin increased the sensitivity of the pregnant myometrium to prostaglandin and it was shown that the combined treatment effectively terminated pregnancy, that a clinicaly useful method became available. The medical method has been used routinely for around 10 years in France, Great Britain, Sweden and China and is now or will soon be introduced in a number of other countries. In Great Britiain and Sweden it is used up to 63 days of amenorrhea while in France and man other countries the upper limits is 49 days of amenorrhea. Up to 49 days, 600 mg mifepristone (Exelgyne, Paris, France) in combination with 0.4 to 0.6 mg misoprostol orally tends to be mostly used while in more advanced pregnancies (50 to 63 days) mifepristone in combination with 1 mg gemeprost vaginally seems more effective. An alternative is vaginal administration of misoprostol, a possibility which is presently evaluated in large multicentre sutdy organized by the World Health Organization. Both the medical and the surgical procedure, vacuum aspiration, are equally effective. Following the medical method, the patient will experience a longer period of bleeding and an amount of blood loss

SEPTEMBER

larger than following vacuum aspiration. The frequency of serious haemorrhage requiring haemostatic curattage (0.8.1.9%) and the frequency of blood transfusion (0.1.0.3%) are, however, similar to those reported for vacuum aspiration. As10 the frequency of presumed pelvic infection requiring antibiotic treatment are the same following medical abortion and vacuum aspiration. Side effects including uterine cramps, nausea and vomiting are more common amend the medical than the surgical abortion patients and occur mainly during the first hours following prostaglandin administration. If the women are allowed to choose both methods are equally acceptable. Common reasons to prefer medical abortion are fear for anesthesia and surgery and the procedure being less invasive and more natural. Adesire to be unconscious and therefor be unaware of the treatment and medical abortion being <> are common reasons for women to prefer vacuum aspiration. All experience indicate that the medical method will not replace but be an alternative to vacuum aspiration. In Sweden both methods are equally often used. Which method is preferred in each individual case is depending on a variaty of personal reasons and can only be decided by the woman herself in consultation with her doctor.

RM1.04.02 OTHER MEDICAL METHODS L. Bornatta, Boston University School of Medicine, Cambridge, United States

MA,

Note: At the time of writing, mifepristone had not been approved by the United States Food and Drug Administration Several agents, developed and released for other indications, have been used for medical abortion. These include methotrexate in combination with misoprostol, and misoprostol alone. Other agents have been investigated but have not shown comparable efficacy to date. Methotrexateimisoprostol has been used mainly in the United States and Canada, where mifepristone availability has been limited to clinical trials to date. Both methotrexate and misprostol are inexpensive, stable, and widely available. Intramuscular methotrexate is used in the United States because it is the least expensive preparation; cost structure is different in other countries. Both oral (50 mg) and intramuscular (50mgim’ or 75 mg) routes have comparable efficacy. Vaginal misoprostol(800 pg, used one or more times) has been used almost exclusively. Success rates (complete medical abortion without a suction procedure) range from 88% to 98%. Where ultrasound was used for initial screening, the rate of continuing pregnancy is reported as 1 - 1.5%, but may actually be lower. Acceptability to women is high. Misoprostol alone has also been used. Altough earlier trials indicated an unacceptably high failure rate, current studies using 800mcg of vaginal misoprostol show abortion rates over 90% in the first nine weeks of pregnancy. For both methotrexate/misoprostol and misoprostol alone, the success rate is inversely related to gestational age. The type of medical practice, expectations of the woman, and experience of the provider may also affect success rates. Rates of curettage for bleeding and incomplete abortion are - 1%.

ss1.04.01 SITUATION ANALYSIS Richard Centers For Disease Control and Prevention, Atlanta, GA, USA Pregnant women in malarious areas may experience a variety of adverse consequences from malaria infection through a cascade of events. Documented adverse consequences of malaria in pregnancy include peripheral parasitemia; maternal anemia; placental accumulation of parasites; placental and peripheral blood immune stimulation with cellular and cytokine responses; low birth weight (LBW) due to both prematurity and intrauterine growth retardation (IUGR); fetal parasite exposure and congenital infection, and infant mortality (IM) linked to preterm-LBW and IUGR-LBW. Through a review of recently published and unpublished studies, we quantified the malaria population attributable risk (PAR) that accounts for both the prevalence of the risk factors in the population and the magnitude of the associated risk for anemia, low birth weight, and infant mortality. Direct adverse consequences from anemia and human immunodeficiency virus (HIV)

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infection in these studies were also considered. PARS were generally substantial: malaria was associated with anemia (PAR range=3%-15%), with LBW (8%.14%), preterm-LBW (8%.36%), IUGR-LBW (13%. 70%), and IM (3.8%). HIV was associated with anemia (PAR range=12%-14%), with LBW (PAR range=ll%-38%), and direct transmission to the newborn 20%.40% of the time with direct mortality consequences. Maternal anemia was associated with LBW (PAR range=7%-18%) and fetal anemia has recently been shown to be associated with increased risk of IM (PAR not available). Overall, we estimate that each year 75,000 to 200,000 infant deaths are associated with malaria infection in pregnancy. The failure to use antimalarial interventions is associated with substantial quantifiable adverse outcomes -suggesting that incorporation of existing effective strategies into antenatal care programs in malarious areas is urgently needed.

ss1.04.02 MALARIA IN PREGNANCY: PREVENTION AND TREATMENT Ednar Dorman, Department of Obstetrics and Gynaecology, Homerton Hospital, London E9 6SR, UK The adverse effects of infection with Plasmodium falciparum in pregnancy vary, depending on the immunity of the woman. Immunity is determined by exposure to infection, and so varies with the intensity of malaria transmission. In non-immune women, infection is usually symptomatic and carries a high risk of maternal and perinatal death. Particular risks are hypoglycaemia, severe haemolytic anaemia, pulmonary oedema and cerebral malaria. In immune women (residents of endemic areas who are regularly exposed to malaria) the infection is often asymptomatic. However, severe and life-threatening maternal anaemia may result and low birth weight deliveries are common, particularly in primigravidae. Coinfection with HIV appears to increase the risk of malaria, regardless of parity. In all cases of symptomatic malaria in pregnancy, prompt treatment with an effective antimalarial is essential. Severe disease should be managed in an intensive care setting where possible, with maintenance of normoglycaemia, transfusion for severe anaemia, and care to avoid fluid overload. Quinine is the most appropriate drug in most circumstances but in the face of parasite resistance, artemesinin derivatives may be used. In endemic areas preventative strategies are necessary, as infection is often asymptomatic and peripheral blood film may be negative. Where the parasite remains sensitive, intermittent presumptive treatment with sulphadoxine-pyrimethamine, given two or three times in pregnancy, has been found to increase birth weight and to prevent 40% of cases of severe maternal anaemia in primigravidae. Avoidance of infection is ideal but, except in areas of very low or highly seasonal transmission, insecticide-treated bednets alone do not provide effective protection in pregnancy. They may have a role in reducing the risk of re-infection after effective drug treatment.

SS1.05 SS1.06 SOLVING THE DILEMMAS, PATIENTS WITH ETHICAL ISSUES (I AND II) .I. Cain (lj, .I. Milliez (2)J. Schencker (3), (1) Pennsylvania State University School of Medicine, Hershey, PA, United States, (2) Hhpital St-Antoine, Paris, France, (3) Hadassah University Medical Center, Israel, Jesuralem You are about to venture into a world where YOU must take the decisions about the “right” thing to do in difficult situations that we encounter in practicing Obstetrics and Gynecology. We will be using the audience response system - so we all will know how many of our colleagues AGREE with our choices. Our distinguished panel will then discuss the arguments for or against different choices and the practical philosophy and ethics that underpin these choices, aided by other members of the FIG0 Committee for the Study of Ethical Issues in Reproduction and Women’s Health. In fact, you will hear how the committee “voted” on some of the same issues, often with a diversity of opinion and thought. YOU can express your particular viewpoint or reason for choosing one or another option as we discuss these choices in deuth.

13 We will be discussing a number of cases. The cases cross issues such as HIV and reproductive technology, elective caesarian section, and making choices about fetal well being. The beginning of the first case provided for your review: Mary is a 36 years old g2pl. Her first pregnancy was 3 years earlier resulting in an uncomplicated normal vaginal delivery of a 3100 gram girl. This pregnancy is a twin gestation diagnosed at 6 weeks of amenorrhera and confirmed at 12 weeks. Ultrasound shows tow distinct and probably dizygous placental sites. During a discussion about amniocentesis, she indicates that she would seek fetal reduction if both were girls. You proceed with amniocentesis and plan to tell her: A. Karyotype without sex B. Karyotype with sex C. Other plan. We look forward to discussing these cases with you.