Placenta previa

This is what a placenta previa looks like. Notice how the placenta completely covers the cervical os:

Birth of Octuplets, Who Gets To Decide?

Photo by peagreengirl

Commenting on the woman who recently gave birth to octuplets conceived via ART, Dr. James Grifo, professor of obstetrics and gynecology at the NYU School of Medicine had this to say:

"I don't think it's our job to tell them how many babies they're allowed to have. I am not a policeman for reproduction in the United States. My role is to educate patients."

I couldn't agree more! The job of telling women what pregnancy decisions they are, and are not, allowed to make and of policing female reproduction is the exclusive purview of:

1. Religionists

2. Politicians

3. Strangers who are not the patient's Ob/Gyn

Pregnant 92-Year-Old Woman

If you're a 60-year-old fetus you had better have some plans for your retirement:

Doctors treating an elderly Chinese woman for stomach ache were stunned when they found that she had been carrying an unborn child for 60 years.

Ninety-two-year-old Huang Yijun, of Huangjiaotan, revealed that her child had died in the womb way back in 1948, and that she did not have it removed because doctors would charge 100 pounds for the job.


"It was a huge sum at the time - more than the whole family earned in several years so I did nothing and ignored it," the Sun quoted her as saying.

The secret surfaced after Huang hurt her stomach, and went to hospital for a scan.

Now, the clinical history is a bit sketchy but the most likely presumptive diagnosis is a lithopedion (litho = stone; pedion = child), or "stone baby." [Warning, graphic pics!]

Lithopedion [Warning, path specimen!]

A lithopedion is a rare phenomenon with only a few hundred cases report in the medical literature. Usually, a lithopedion occurs after a fetus dies during an ectopic abdominal pregnancy and is too large to be reabsorbed by the body (EGA 14 wks and up).

To shield itself from the degenerating tissue of the fetal foreign body the woman's body will encase the fetus and/or its covering membranes in a calciferous substance.

Believe it or not, forming a lithopedion is a best case scenario. The alternatives, from Williams 21ed, p. 900 (text references omitted):

If the fetus dies before reaching a size too large to be resorbed, it may undergo suppuration, mummification, or calcification. Bacteria may gain access to the gestational products, particularly when they are adherent to intestines, resulting in suppuration. Eventually, the abscess ruptures, and if the woman does not die of peritonitis and septicemia, fetal parts may be extruded through the abdominal wall or more commonly into the intestine or bladder. Mummification and formation of a lithopedion occasionally ensue, and calcified products of conception may be carried for years. There are instances in which a period of 20 to 50 years elapsed before removal of a lithopedion at operation or autopsy. Much more rarely, the fetus is converted into a yellowish, greasy mass to which the term adipocere is applied.

The body is quite an amazing apparatus, no?

Top Ten Benefits of Delivering Your 18th Child in America

Photo by Welt Online

By immigrating to Canada, instead of here, Livia Ionce, the 44 yo Romanian woman who just gave birth to her 18th child, missed out on a whole lot o' reproductive health advantages.

According to the husband:

We never planned how many children to have. We just let God guide our lives, you know, because we strongly believe life comes from God and that's the reason we did not stop the life," said Alexandru Ionce.

So the Ionce's made a particular reproductive choice--not to plan the pregnancies- based on a particular personal belief. Which personal choice and belief, had they immigrated to the U.S., would've entitled Mrs. Ionce to the following top 10 benefits (in no particular order):

1. Hospitals and doctors who refuse to admit/deliver her because of the pregnancy decision she made.

2. State laws that force doctors to lie to her about her medical condition if she elects to have prenatal care and deliver.

3. Pharmacists who steal her prescription for prenatal vitamins.

4. Nurses who get CME credit for lectures on how their forced abortion beliefs trump her beliefs and medical needs.

5. Fake L&D facilities designed to trick her into aborting her pregnancy.

6. Noble First Amendment crusaders who expose her young children to graphic pictures of vaginal and rectal tears, C/Ss and hysterectomies.

7. Mandatory counseling and waiting period before being allowed to proceed with her reproductive choice, if, and only if, her choice is to carry the pregnancy to term and deliver it.

8. A forced vaginal U/S while reading a sign stating that it's "against the law for anyone, regardless of his or her relationship to you, to force you to carry the pregnancy to term" to insure her decision to do just that is fully informed.

9. HHS defining her medical condition based on polls and personal beliefs.

10. A SCOTUS decision banning vaginal deliveries and decreeing C/S the standard of care for deliveries of grand multips.

Oh.....wait a minute. The Ionce's did not make a different reproductive choice, one where you plan how many children, if any at all, to have. They also happen to believe in a God [a Western one, presumably] sanctioned as The Correct God(TM) by the current U.S. government.

Never mind then; ignore the list.

Only those who make the, you know, wrong reproductive choice are entitled to benefit from government supervision and intrusion in their lives and medical decisions. Them people and those whose personal beliefs are deemed wrong by the State, of course.

Pregnancy Spacing

Photo by freeparking

If you want to have more than one child, how long should you wait between pregnancies?

According to the results of a study from India, [b]irth intervals of less than 18 months are associated with high risk of stillbirth and neonatal deaths, while [a] birth-to-pregnancy interval of 24 months is optimal.

The researchers conclude:

"Postpartum family planning should be promoted for all women, and methods both for spacing and limiting birth should be widely accessible"....

If the political climate in India is anything like the one here, good luck with translating that recommendation into practice.

Your Brain On Pregnancy

A fluid-attenuated inversion-recovery MRI of a formerly eclamptic patient reveals white matter lesions (arrows). Neuro-Imaging Center of the School of Behavioural and Cognitive Neurosciences in Groningen

If you develop eclampsia [high blood pressure and seizures] during pregnancy, does your brain return to normal postpartum?

Maybe, maybe not, according to recent findings that challenge the current opinion that eclampsia is a one-time event from which women can expect a full clinical recovery.

A study looked at 103 women and found white matter brain lesions in:

- 41% formerly eclamptic women

- 29% formerly preeclamptic women [high blood pressure; no seizures]

- 17% women who had a normotensive pregnancy [normal blood pressure]

Moreover:

The researchers also observed that the number of eclamptic seizures appeared to be related to the presence and severity of the brain matter lesions. In all, 19 eclamptic women had one grand mal seizure, 10 had two, and 10 had three or more. Women who reported three or more eclamptic seizures were three times more likely to have white matter lesions than were women with no seizures, she said.

The total volume of the lesions was significantly greater among formerly eclamptic women than controls (0.04 mL vs. 0.004 mL).

U.S. On Par With Belarus, But Worst Than Macedonia And Bosnia

When it comes to women dying from complications of pregnancy or childbirth, that is:

WASHINGTON (Reuters) - The United States has a sharply higher rate of women dying during or just after pregnancy than European countries, even some relatively poor countries such as Macedonia and Bosnia, according to the first estimates in five years on maternal deaths worldwide.

The report released by various United Nations agencies and the World Bank on Friday shows that Ireland has the lowest rate of deaths, while several African countries have the worst.

The United States has a far higher death rate than the European average, the report shows, with one in 4,800 U.S. women dying from complications of pregnancy or childbirth, the same as Belarus and just slightly better than Serbia's rate of one in 4,500.

Just one out of 47,600 women in Ireland die during or just after childbirth, the report found. Bosnia had the second-lowest rate, with 1 in 29,000 women dying during pregnancy and childbirth.

"Among the ten top-ranked European and other industrialized countries, where women are guaranteed good-quality health and family planning services that minimize their lifetime risk, fewer than one in 16,400 will die from complications of pregnancy and childbirth," the United Nations, which issued the report along with the World Bank, said in a statement.

...

The report, published in the Lancet medical journal, places the United States 41st among 171 countries.

The four lowest-ranked countries in the report are Chad, with 1 in 11 women dying in pregnancy or childbirth, Afghanistan and Sierra Leone with one in eight, and Niger losing one in seven mothers.

...

According to the U.S. National center for Health Statistics, about 6 million U.S. women get pregnant every year. Four million children are born, about 1 million pregnancies end in miscarriages and another 1 million in induced abortion.

The major direct causes of U.S. pregnancy-related deaths are blood clots, hemorrhage, complications of medical conditions, and eclampsia and pre-eclampsia, which are marked by dangerously high blood pressure.

The death rate among U.S. black women was nearly four times the rate found among non-Hispanic white women -- 34.7 deaths per 100,000 live births for blacks versus 9.3 per 100,000 live births for whites, the report said.

With about 6 million pregnancies per year here in the U.S. you can't help but feel for all those recruits training to be part of the demographic command units to be activated once abortion is banned in the U.S. What with all the mandatory monthly gynecological examinations for all women of childbearing age, miscarriage investigations, surveillance of childless women and couples, I'm afraid those poor people will have their hands full, in more ways than one.

Dangerous Female Blood Donors?

An interesting article about a possible side effect of pregnancy:

[B]lood banks are beginning to separate out women's plasma — the liquid part of blood — in an effort to fight a mysterious lung injury that has become the nation's leading risk from transfusions.

Ask about blood safety and most people think of HIV or other diseases that, thanks to strict testing, actually are incredibly rare in U.S. transfusions. Today the top threat is TRALI, or "transfusion-related acute lung injury," in which transfusions trigger reactions that fill patients' lungs with fluid, leaving them gasping for air.

There are no good counts, although TRALI is thought to strike a few hundred people a year and kill roughly 10 percent of them. It's a condition doctors don't always recognize since patients who need transfusions are seriously sick to begin with, but it's starting to gain attention.

...

No one knows exactly what causes TRALI. But certain immune cells carried by women who have been pregnant are emerging as a chief culprit, cells called antibodies that mothers-to-be produce in reaction to their fetus' foreign father cells.

The antibodies do no harm to mother, baby or the vast majority of people who encounter them in a transfusion. To get TRALI requires what Celso Bianco of America's Blood Centers calls "a horrible coincidence" in which the transfusion recipient has white blood cells that just happen to recognize and clash with the donor's antibodies.

More on transfusion-related acute lung injury (TRALI):

The perception or fear that, nowadays, infections represent the most frequent cause of serious complications associated with transfusions of blood or blood derivatives may be unfounded. As illustrated by the causes of the few fatalities occurring after a transfusion that were reported to the US Food and Drug Administration (FDA) before 1995, hemolytic reactions (mostly due to ABO incompatibilities) represented the leading cause of death (50% to 62%), while respiratory syndromes represented the second leading cause (15% of fatalities). Bacterial contamination followed in the third place with a 10% to 16% frequency over the past 25 years.

Since the introduction of nucleic acid testing in 1999, transfusion-related viral infections have become a rare event -- only 3 documented cases per year. The specific risks have been calculated as follows: 1/205,000 transfusions for hepatitis B, 1/1,935,000 for hepatitis C, 1/2,135,000 for HIV 1 and 2 infections, and 1/2,993,000 for HTLV infections.

TRALI is Underrecognized

The respiratory distress syndrome associated with transfusions, called TRALI (transfusion-related lung injury), on the other hand, constitutes a serious risk that may be presently underestimated, as it often goes unrecognized and undertreated. Currently, at least 6 deaths per year are being formally attributed to TRALI. The actual prevalence is, however, probably far higher with an estimate of about 200 patients per year being affected.

According to detailed studies, TRALI might occur in 1/5000 transfusions, or as frequently as 1/300 transfusions of red blood cell derivatives. Others reported a frequency of 1/1323 in a recent study. Approximately 12 million transfusions are given per year in the United States. Something is amiss when only 6 cases of TRALI are officially diagnosed and reported. Data obtained in the United Kingdom from the SKOT (a confidential voluntary reporting system) seem to be aligned with this trend. Eighteen cases of acute lung injuries have been reported in 2000, ranking TRALI as the second most frequent cause (6 deaths) of transfusion-related complications after hemolysis.

...

Treatment and Prognosis of TRALI

Treatment of TRALI requires interruption of the transfusion and ventilation with hemodynamic support. Diuretics and corticosteroids should not be given. Blood products should not be withheld if there is clinical indication. The risk of recurrence for TRALI is unknown, but it is being estimated at approximately 10%. The vast majority of cases, more than 80%, resolve within 96 hours with ventilatory support. With appropriate treatment, resolution is generally complete and no residual damages are observed in patients.

Etiopathogenesis

Which blood products may induce TRALI in a patient? Most, if not all, blood products have been linked to TRALI: whole blood, red blood cells, platelets (whole blood- or apheresis-derived), and granulocytes. TRALI has been found to be only rarely associated with administration of cryoprecipitates and intravenous immunoglobulins. Plasma, on the other hand, seems to be the blood product most frequently associated with TRALI, particularly units that contain more than 100 mL of plasma.

Donor-Derived Antibodies

Two, nonmutually exclusive, theories are being investigated as the possible cause of this respiratory syndrome feeding a bit into a climate of controversy. According to some investigators, donor-derived antibodies present in the transfused products react with the recipients' own blood cells, inducing release of inflammatory mediators. Anti-HLA antibodies are the most frequently "indicted" inducers in this category.

...

Multiparous women are very good long-term blood donors, but owing to the multiple pregnancies, they may develop higher than usual titers of HLA antibodies to the fetal HLA antigens of paternal origin. Generally, only approximately 8% of the general population has detectable antibody titers vs more than 20% of multiparous women with more than 2 pregnancies. Does this etiopathogenetic theory imply that this donor group may carry a higher risk of inducing TRALI in the recipients?

A retrospective study published by Kopko and colleagues seems to suggest that, at times, there may be a correlation. In this study, the clinical histories of 50 recipients of blood transfusions from a 54-year-old multiparous woman (3 pregnancies) were evaluated retrospectively. Fifteen of the 36 evaluable recipients had developed transfusion-related respiratory complications: 7 with mild to moderate symptoms and 8 with a severe reaction. TRALI was formally diagnosed and reported only in 2 of these patients. In another investigation, 102 recipients of more than 2 units of plasma (FFP) prepared from multiparous women were studied retrospectively for complications. A total of 5 transfusion-related reactions had been reported, and only 1 as TRALI. These data are, however, of limited usefulness as antibodies titers and specificities were not evaluated in these recipients/patient combinations.

...

Donor-Derived Lipids

The second theory mainly advocated by a single research group for the pathogenesis of TRALI points to lipids as the inducers of this syndrome. The presence of such lipids would increase over time in the donors' units, leading to accumulation of biologic mediators able to induce TRALI upon transfusion. Cell-rich blood products rather than plasma would thus carry the highest risk of transfusion reactions. The presence of lipid mediators would also be associated with autologous transfusions (transfusions of the patients' own blood cells or plasma). According to this hypothesis, the longer the storage, the higher the risk of developing TRALI.

A clinical case that might be ascribed to a lipid-induced TRALI is, in fact, that of the "autologous" TRALI. In this case, a 62-year-old man undergoing radical prostatectomy received 2 units of autologous blood (18 and 25 days old, respectively). After transfusion of the second unit, the patient experienced marked hypotension and hypoxemia. Symptoms resolved after interruption of the transfusion. No cardiac dysfunction and no volume overload were observed. The presence of bioactive lipids was later documented in the stored red blood cell units.

Practical Implications

Thus, according to the experimental results reported so far, both explanations may account for the occurrence of lung injury during TRALI. The relative role of each mechanism in the induction process is, however, being hotly disputed. While researchers investigating the pathogenetic role of antibodies report that up to 50% of TRALI cases appear to be antibody-mediated, Silliman's group found antibodies only in approximately 4% of cases claiming that the lipid priming activity would be responsible for most of the TRALI cases observed.

...

More data would also shed light on questions that are, at the moment, unanswered, but that could influence standards of practice in transfusion medicine. Should donors be screened for the presence of leukoagglutinins? Should each unit be tested before transfusion for the presence of antibodies or lipid mediators? Should reverse lymphocyte crossmatches be performed?

As pointed out by Dr. Eder, the lack of agreement on the cellular and molecular mechanisms underlying the development of TRALI renders the task of improving the safety of blood transfusion far more complex and potentially more expensive.

...

Two types of transfusions that are frequently perceived as "safer" by the general public may carry, in fact, a higher risk of TRALI: autologous components and maternal transfusions. While autologous transfusions would not be advisable on the basis of the long-term storage theory, maternal transfusions are contraindicated in some cases, owing to the high chance of having matching anti-HLA antibodies directed to the child's antigens of paternal origin, particularly after the second pregnancy (if the 2 children have the same biological father).

While we wait for a resolution of this etiopathogenetic controversy, more accurate diagnoses, a closer monitoring of patients, and a timely delivery of appropriate treatment will certainly help in making TRALI less of a burden in the posttransfusional setting.

Reproductive Health Risks

Interesting article on reproductive risks by Dr. Trussell in Contraception. [Not sure if you can access the article without a subscription, so I'll quote in full.]:

Volume 73, Issue 5, Pages 437-439 (May 2006)

Reproductive health risks in perspective

James Trussell

Beth Jordan

Dramatic headlines about women's health — deaths of women using the OrthoEvra patch, for example, or after medication abortion — can quickly lead patients and healthcare practitioners into a state of panic and uncertainty over the appropriate course of action to take. Should therapy be continued or not? What is the real risk of death?

Alarmist, misleading, inaccurate or incomplete media coverage is certainly a source of confusion, but such stylized reporting is not likely to be eliminated from most large media outlets in the near future. That fact, coupled with the lack of courses in biostatistics and risk-assessment analysis in most medical training programs and the reality that health professionals have little time to counsel patients about the risks of various treatments, can lead patients to make poor health-related choices.

This danger is particularly worrisome when patients are dealing with contraceptive issues and the threat of an unplanned pregnancy. Doctors, nurses and other providers have little time to investigate and consolidate risk-related information for their patients, and patients have few resources available to help them ascertain the risks from using various contraceptive methods. The brief summary provided here is intended to help inform clinicians and their patients of the risk of death from pregnancy, abortion and the use of various forms of hormonal contraception, as well as from other voluntary activities.

In general, contraceptives pose few serious health risks to users. Moreover, the use of contraceptive methods is generally far safer than pregnancy. Unintended pregnancies unnecessarily place women at risk. Women in many developing countries will experience an even greater advantage in using contraceptive methods than those in the developed world in comparison with pregnancy-related mortality. Nonetheless, use of some contraceptive methods may entail potential risks.

• Use of the method may lead to serious outcomes such as death, hospitalization, surgery, medical side effects, infections, loss of reproductive capacity or pain.

• Contraceptive failure (pregnancy) is associated with risk: a woman must assess the likelihood of contraceptive failure and the dangers that a pregnancy would pose.

• Future fertility may be influenced by choice of a contraceptive method.

When it comes to the most serious outcome of all — death — the absolute level of risk is extraordinarily low for most women. Table 1 puts into perspective some of the risks of everyday life in the United States [1–9]. Other major health risks from contraceptive use are not only uncommon, but they are also most likely to occur in women who have underlying medical conditions.

Table 1.

Everyday risks in perspective

	Activity	Risk of death	Source
	Risk per year
	While skydiving	1 in 1000	Laudan [1]
	From an accident	1 in 2900
	From an automobile accident	1 in 5000
	From a fall	1 in 20,000
	From a fire	1 in 50,000
	From riding your bicycle	1 in 130,000
	In an airplane crash	1 in 250,000
	From being struck by lightning	1 in 2,000,000
	Risk per year for women preventing pregnancy
	Using OCs		Schwingl et al. [2]
	Nonsmoker
	Aged 15–34 years	1 in 1,667,000
	Aged 35–44 years	1 in 33,300
	Smoker
	Aged 15–34 years	1 in 57,800
	Aged 35–44 years	1 in 5200
	Undergoing tubal sterilization	1 in 66,700	Escobedo et al. [3]
	Risk per year from using tampons	1 in 5,734,000	Hajjeh et al. [4]; U.S. Census Bureau [5]
	Risk from pregnancy	1 in 8700	Berg et al. [6]
	Risk from spontaneous abortion	1 in 142,900	Saraiya et al. [7]
	Risk from legal induced abortion
	Mifepristone/misoprostol	1 in 110,000	Summers [8]
	Surgical	1 in 142,900	Bartlett et al. [9]
	≤8 weeks	1 in 1,000,000
	9–10 weeks	1 in 500,000
	11–12 weeks	1 in 250,000
	13–15 weeks	1 in 58,800
	16–20 weeks	1 in 29,400
	≥21 weeks	1 in 11,200

Pregnancy

The risk of death from pregnancy and delivery is about 1 in 8700, lower than the annual risk of death from an automobile accident but higher than the annual risk of death from use of combined oral contraceptives (OCs) for all women except those aged 35–44 years who smoke and higher than the risk of death from abortion, even at gestational ages ≥21 weeks.

Combined OCs

Combined OCs have been associated with an increased risk of myocardial infarction (MI) and stroke. Smoking definitely increases the risk of MI, especially in women older than 35 years. However, nonsmoking, normotensive, nondiabetic women of any age who use combined OCs are not at increased risk for MI. The risk of stroke in nonsmoking women younger than 35 years is not increased by use of OCs with less than 50 μg of estrogen [10]. The risk of venous thromboembolism is increased by combined OC use, but the absolute risk of this increase is quite low among women who use OCs with less than 50 μg of estrogen, ranging from 9 events per 100,000 women-years of exposure among those aged 20–24 years to 18 events per 100,000 women-years of exposure among those aged 40–44 years [10].

Use of combined OCs is associated with a decreased risk of cancers of the endometrium and ovary and an increased risk of cancer of the cervix and liver, a small increased risk of breast cancer in young women and a decreased risk of colorectal cancer [10]. However, there is great uncertainty regarding the causal link, if any, between combined OC use and liver and colorectal cancer [10], and recent evidence suggests no association between current or former combined OC use and breast cancer [11]. Regardless, the net effect of pill use on cancer is negligible [10].

Persistent infection with certain types of human papillomavirus (HPV) is the most frequent cause of cervical cancer. However, the incidence of cervical cancer is increased in women using OCs, particularly long-term users, even among women infected with HPV; this risk increases as duration of use increases [12]. Results from limited data also suggest a slight increase in the risk of cervical cancer among women who use injectable contraceptives for 5 years or longer [12].

Analysis of pooled data from 54 epidemiologic studies conducted in 25 countries found that women have a slightly increased risk (about 25% higher) for having breast cancer diagnosed while they are using OCs. Cancers diagnosed in these women are less advanced clinically than those diagnosed in women of the same age who have never used OCs [13]. The increased risk is apparent soon after pill use begins but does not increase with duration of use, declines after use ceases and does not persist beyond 10 years after exposure ceases. These patterns are not typical for a carcinogenic agent but would be consistent with promotion of already existing tumors or with earlier diagnosis of breast cancer in women who have used the pill. A more recent study in the United Sates found that among women aged 35–64 years, current or former combined OC use is not associated with an increased risk of diagnosis of breast cancer [11].

OrthoEvra patch

The OrthoEvra patch has been recently highlighted in the press after the Food and Drug Administration (FDA) announced a label change in October 2005. The change includes a bolded "warning" indicating that use of the patch entails a 60% higher exposure to estrogen than use of a typical combined OC containing 35 μg of estrogen; however, the FDA states that the clinical relevance of this finding is unknown [14].

The actual risk of death from patch use is impossible to determine. Spontaneous reports of deaths of women using the patch have been received by the FDA. Spontaneous reports to the FDA can come from various sources, and the quality and extent of the information reported vary considerably. It is often unclear whether a death is causally related to use of a drug. Moreover, even if the intensive follow-up was to establish that a certain number of deaths were likely to have been caused by use of that drug, there remains the problem of computing an accurate mortality rate because the relevant denominator is also not known. Therefore, it is not possible to know at this time how the mortality risk from use of the patch compares with that from use of combined OCs [15].

Abortion

The risk of death is about the same from medication abortion and from surgical abortion; however, the risk of death from surgical abortion is greatest for higher gestational ages where medication abortion is not used. Nevertheless, induced abortion is safer than continuing pregnancy and entails about the same risk as spontaneous abortion.

Conclusion

As sensationalized news reporting becomes more common and thoughtful analysis becomes more difficult to find, given its perceived lack of appeal to media observers, healthcare practitioners must intensify efforts fully and repeatedly to inform patients of their true risks of death from various contraceptive methods. This imperative is particularly important as the FDA has become extremely sensitive regarding drug safety warnings.

Women are far more likely to die from pregnancy-related complications, from automobile accidents or from a fall than they are from using hormonal contraception or having undergone either a medication or surgical abortion. Those who claim that hormonal contraception and abortion are unsafe base this assertion on ideology, not evidence-based science. The evidence in Table 1 shows otherwise.

References

1. Laudan L. The book of risks. New York: John Wiley and Sons; 1994;.

2. Schwingl PJ, Ory HW, Visness CM. Estimates of the risk of cardiovascular death attributable to low-dose oral contraceptives in the United States. Am J Obstet Gynecol. 1999;180:241–249. Abstract

3. Escobedo LG, Peterson HB, Grubb GS, Franks AL. Case-fatality rates for tubal sterilization in U.S. hospitals, 1979–1980. Am J Obstet Gynecol. 1989;160:147–150. MEDLINE

4. Hajjeh RA, Reingold A, Weil A, Shutt K, Schuhat A, Perkins BA. Toxic shock syndrome in the United States, 1979–1996. Emerg Infect Dis. 1999;5:807–810. MEDLINE

5. U.S. Bureau of the Census . Statistical abstract of the United States: 2003. Washington (DC): Government Printing Office; 2003;[Table 11].

6. Berg CJ, Chang J, Callaghan WM, Whitehead SJ. Pregnancy-related mortality in the United States, 1991–1997. Obstet Gynecol. 2003;101:289–296. MEDLINE

7. Saraiya M, Green CA, Berg CJ, Hopkins FW, Koonin LM, Atrash HK. Spontaneous abortion-related deaths among women in the United States — 1981–1991. Obstet Gynecol. 1999;94:172–176. MEDLINE

8. Personal communication from Danco Laboratories, C Summers. 9 March 2006.

9. Bartlett LA, Berg CJ, Shulman HB, et al.. Risk factors for legal induced abortion-related mortality in the United States. Obstet Gynecol. 2004;103:729–737. MEDLINE

10. Burkman R, Schlesselman JJ, Zieman M. Safety concerns and health benefits associated with oral contraception. Am J Obstet Gynecol. 2004;190(Suppl):S5–S22. Abstract

11. Marchbanks PA, McDonald HG, Wilson HG, et al.. Oral contraceptives and the risk of breast cancer. N Engl J Med. 2002;346:2025–2032.

12. [12]Smith JS, Green J, Berrington de Gonzalez A, et al.. Cervical cancer and use of hormonal contraceptives: a systematic review. Lancet. 2003;361:1159–1167. Abstract

13. Collaborative Group on Hormonal Factors in Breast Cancer . Breast cancer and hormonal contraceptives: collaborative reanalysis of individual data on 53,297 women with breast cancer and 100,239 women without breast cancer from 54 epidemiological studies. Lancet. 1996;347:1713–1727. MEDLINE

14. Ortho-McNeil Pharmaceutical. Ortho Evra Product labeling. Revised November 2005.

15. Media report on Ortho Evra patch sets off safety concerns in women. Contracept Technol Update. 2005;26:113–115.