Influence of past reproductive performance on risk of spontaneous abortion.

OBJECTIVE--To investigate the incidence of spontaneous abortion in a population of women in order to establish their risk of spontaneous abortion and the obstetric factors predisposing to it. DESIGN--Prospective study of women recruited by radio and poster appeal and from hospital outpatient clinics. SETTING--English provincial community. PATIENTS--630 Women from the general population intending to become pregnant. INTERVENTIONS--The viability of the pregnancy was assessed by abdominal ultrasonography before completion of the eighth week, and the assessment was repeated if vaginal bleeding occurred. MAIN OUTCOME MEASURE--Spontaneous abortion or live births in women with or without a previous history of spontaneous abortion. RESULTS--The overall incidence of clinically recognisable spontaneous abortion before 20 weeks of gestation was 12% (50/407 pregnancies). The risk of spontaneous abortion in each category of patient was classified with respect to the patient''s past reproductive performance and found to be influenced greatly by her previous obstetric history. In primigravidas and women with a history of consistently successful pregnancies the incidences of abortion were low (5% (4/87) and 4% (3/73) respectively), whereas women with only unsuccessful histories had a much greater risk of aborting the study pregnancy (24% (24/98)), even when their sole pregnancy had ended in abortion (20% (12/59)). The outcome of the last pregnancy also influenced the outcome of the study pregnancy; only 5% of women (5/95) whose previous pregnancy had been successful aborted, whereas the incidence of loss of pregnancy among women whose last pregnancy had aborted was 19% (40/214). CONCLUSIONS--A knowledge of the patient''s reproductive history is essential for the clinical assessment of her risk of spontaneous abortion. As the most important predictive factor for spontaneous abortion is a previous abortion, the outcome of a woman''s first pregnancy has profound consequences for all subsequent pregnancies.     

Abortion experience among obstetric patients at Korle-Bu Hospital, Accra, Ghana

Hospital admissions for complications of abortion have been increasing in Africa, indicating a rise in the incidence of abortion. In all pregnant women ever admitted to Korle-Bu hospital in Accra, Ghana, the chance that the outcome of their last pregnancy was an induced abortion decreased as the number of previous pregnancies increased. Women with higher levels of education were more likely to have their 1st pregnancy terminated in an induced abortion. Younger women were more likely than older women at each level of education to have an induced abortion terminate a 1st pregnancy. The use of contraceptives during the last pregnancy interval increased with the level of education of the woman and the number of previous pregnancies. Contraceptive use was also highest among women whose last pregnancy outcome was an induced abortion. The mean pregnancy interval decreased with increasing number of previous pregnancies for both women who used and who did not use contraceptives during their last pregnancy interval. But the mean pregnancy interval was higher among women who used contraceptives. It appears that the abortion experience in this region of Africa is most common in lower parity young women with high levels of education who desire to delay a 1st birth or to space births. This is in contrast in Latin America and other developing countries in which abortion is used mainly by older, married, urban women to limit family size. Contraceptive use in this region of Africa is low, indicating the need for more family planning programs and increasing use of existing programs.     

Prostaglandin-induced abortion and outcome of subsequent pregnancies: a prospective controlled study

We analysed a prospective series of 204 pregnancies occurring in 168 women after a prostaglandin-induced abortion. The mean (±standard error of mean) interval between abortion and first subsequent conception was 10·4 ± 0·6 months; no patient reported secondary subfertility.Fifty-five of the subsequent pregnancies were terminated, 23 during the second trimester, again using prostaglandins. Of the 149 pregnancies not terminated, 127 were delivered at term, and 19 spontaneously aborted, seven during the second trimester; there was one missed abortion and two ectopic pregnancies. Morbidity in the 127 term pregnancies was infrequent; spontaneous preterm labour occurred in three patients, and four singleton infants weighed less than 2500 g at birth. There was no apparent association between morbidity in the subsequent pregnancies and the period of gestation at the time of the previous abortion, route of prostaglandin administration, or need for post-abortion curettage.The results obtained overall were very similar to a control group of 612 women consecutively admitted for delivery or abortion to the Oxford obstetrical and gynaecological units. There was, however, an increased incidence of spontaneous abortion and placenta praevia after prostaglandin-induced abortion, and the multigravidae in that group had a longer average duration of labour than the control group. Sixty-five per cent of the post-abortion pregnancies were unplanned compared with 36% of the control group.     

Dydrogesterone in threatened abortion: pregnancy outcome

OBJECTIVE: To determine whether therapy with dydrogesterone in threatened abortion during the first trimester of pregnancy will improve pregnancy outcome. DESIGN: Prospective open study. SUBJECTS: Pregnant women presenting to the obstetric and gynaecology clinic admitting center with vaginal bleeding before 13 weeks gestation were evaluated for entry into the study. Women were excluded if they had a history of recurrent miscarriage. METHOD: Eligible subjects were randomized to receive either dydrogesterone 40 mg stat dose followed by 10 mg twice a day for one week or conservative therapy. RESULTS: One hundred and 54 women were recruited. There was no statistically significant differences between the two groups with regard to pre-treatment status. The continuing pregnancy success rate was significantly (p=0.037) higher in women treated with dydrogesterone (95.9%) compared with women who received conservative treatment (86.3%). The odds ratio of the success rate between dydrogesterone treatment and non-treatment was 3.773 (95% confidence interval: 1.009-14.108). CONCLUSION: Corpus luteal support with dydrogesterone has been shown to reduce the incidence of pregnancy loss in threatened abortion during the first trimester in women without a history of recurrent abortion.     

Placental Lactogen Levels as Guide to Outcome of Threatened Abortion

The clinical value has been assessed of circulating placental lactogen levels as a pointer to the outcome in a patient with vaginal bleeding in early pregnancy. By using a semiautomated radioimmunoassay the normal range of values for the first and second trimesters has been established. In patients admitted with vaginal bleeding after the eighth week of gestation estimation of plasma human placental lactogen showed that patients with low levels were those in whom the abortion was completed during the first admission. Women whose pregnancies continued normally or who aborted after their first discharge from hospital had normal levels. In a small group sampled before the onset of bleeding but who later aborted the mean levels were lower than normal. This simple and inexpensive test can indicate those women in whom abortion is inevitable and could be used to reduce substantially the length of hospital stay in this common complication of early pregnancy.     

Recurrent spontaneous abortion and polycystic ovarian disease: comparison of two regimens to induce ovulation.

OBJECTIVE--To determine whether pituitary suppression before induction of ovulation reduces the rate of spontaneous abortion in women with polycystic ovarian disease and primary recurrent spontaneous abortions. DESIGN--Closed, randomised, sequential trial. Pairs of women were allocated to each treatment by the toss of a coin. SETTING--Supraregional clinic for women who had had recurrent spontaneous abortions. SUBJECTS--Forty two women with polycystic ovarian disease and primary recurrent spontaneous abortions. INTERVENTIONS--Ovulation was induced by clomiphene or pituitary suppression with buserelin followed by pure follicle stimulating hormone. MAIN OUTCOME MEASURES--Preference for a particular treatment was noted. A preference occurred when one woman in a pair had a successful pregnancy (defined as one of over 12 weeks'' gestation) and one had a spontaneous abortion; the preference was for the treatment resulting in the successful pregnancy. RESULTS--Spontaneous abortions occurred in 11 of 20 women given clomiphene compared with two of 20 who had pituitary suppression. Eleven preferences were found for buserelin and two for clomiphene. In seven pairs both women had successful pregnancies. One pair was discarded because one of the women did not become pregnant. The ratio of luteinising hormone concentration to follicular diameter was found to be a possible diagnostic indicator of spontaneous abortion. CONCLUSION--Pituitary suppression before induction of ovulation significantly reduces the risk of spontaneous abortion in women with polycystic ovarian disease and primary recurrent spontaneous abortions.     

Induced abortion in Sri Lanka: who goes to providers for pregnancy termination?

The sociodemographic characteristics of abortion seekers and the reasons they give for procuring termination were studied in 356 clients selected from two abortion clinics in the city of Colombo. Nearly 80% were Buddhists and about 10% were Christians. Almost all had some formal education but only 20% were employed outside the home. Over 95% were currently married and at the peak of their childbearing age. More than one-half were aged 30 years or over, while adolescents only constituted about 3%. Fourteen per cent were nulliparous and about two-thirds had one or two living children at the time of obtaining the abortion. A significantly high proportion also had a very young child. In total, the 356 women had had 1130 pregnancies, and the mean rate of abortion was 42 per 100 pregnancies. Over one-quarter had had more than one abortion and about 10% had had three or more. Almost all abortions were performed within the first trimester with a mean gestation period of 6 weeks. About one-third of the clients were using some method of contraception at the time they became pregnant. The most common reasons cited for the present abortion were 'pregnancy too soon after previous delivery', 'no more children desired' or 'curtailment of opportunity for foreign employment'. Unmarried women constitute a special group of abortion seekers who have different needs and behave differently from married women. Their needs are not currently being met by reproductive health programmes in Sri Lanka, and it is important that they should be given special attention in the future. An interesting finding is that a significant minority of the abortion seekers answered negatively to the question regarding providing medical facilities for abortions without difficulty. This underscores the ambivalence many people have to abortion.     

Course of pregnancies in women with Cushing's disease treated by gamma-knife

Data concerning pregnancy in women with Cushing's disease treated by gamma-knife (GK) are scanty. We present and discuss the course and outcome of five pregnancies in two women with Cushing's disease (CD), the first of whom was treated only by GK, and the second one treated by surgery, GK and ketoconazole. In the first patient, pregnancy was uneventful and full-term. During gestation, plasma ACTH, serum cortisol and 24-h urinary free cortisol (UFC) levels were steady, and always in the normal range for healthy non-pregnant individuals. The newborn was healthy and normal-weight. In the second woman, two pregnancies, occurring 3 years after GK and few months after ketoconazole withdrawal, were interrupted by spontaneous abortion or placental disruption despite normal cortisol levels. This patient became again pregnant 3 years later and delivered vaginally a healthy full-term infant. Seven months after the delivery, the patient became pregnant again and at the 39th week of gestation delivered vaginally a healthy male. Hypoprolactinemia and/or central hypothyroidism occurred in both cases. In women with CD treated by GK, pregnancy can occur. However, pregnancy is at risk even when ACTH and cortisol levels are normalized by treatment. After GK, evaluation of pituitary function is mandatory due to the risk of hypopituitarism.     

A retrospective study of 932 second trimester terminations using gemeprost (16,16 dimethyl-trans delta 2 PGE1 methyl ester).

A retrospective study of 932 second trimester terminations between 12-27 weeks gestation was carried out to determine the efficacy of gemeprost for second trimester termination. A single course of 5 x 1 mg gemeprost pessaries was administered every three hours. If abortion had not occurred after the first course of pessaries, a further course of 5 x 1 mg pessaries was administered. Intravenous oxytocin was administered after 36 hours if abortion had not occurred. Eighty per cent and ninety five per cent of patients aborted within 24 and 48 hours respectively. Of the remaining 5 per cent of women, 3 per cent aborted with escalating doses of oxytocin. In the remaining 18 (2 per cent) women, the pregnancies were electively terminated with an alternative method. The median induction-abortion interval was 18.0 hours and 15.0 hours in nulliparous and parous women respectively (P less than 0.0001). The number of pessaries required to induce abortion was not influenced by parity. Significantly more parous women bled more than 500 ml. The incidence of pelvic sepsis (0.1 per cent) and cervical tear (0.1 per cent) was low. Twenty six per cent of women had diarrhoea and 23 per cent vomited following administration of prostaglandin. This study confirmed the efficacy of gemeprost for second trimester termination of pregnancy. This method of termination is safe, non-invasive, simple and has a low complication rate.     

Abortion induced with methotrexate and misoprostol.

OBJECTIVE: To determine the outcome and side effects of a new drug protocol to induce abortion. DESIGN: Case series. SETTING: An urban primary care practice. PATIENTS: One hundred consecutive patients who requested elective termination of pregnancies of less than 8 weeks'' gestation. INTERVENTION: Subjects received methotrexate (50 mg/m2 body surface area, administered intramuscularly) and, 3 days afterward, misoprostol (800 micrograms, given vaginally). OUTCOME MEASURES: Number of abortions induced within 24 hours and within 10 days of misoprostol administration, number of surgical aspirations conducted because of incomplete abortion, mean amount of bleeding and pain and the number of women who, if faced with the same situation, said they would again choose a drug-induced abortion over a surgical one. RESULTS: Abortion occurred within 24 hours of misoprostol administration among 48 women and within 10 days among 69 women. In total, 89 women had an abortion without surgical aspiration. Of these women, 71 said they would choose a drug-induced abortion if faced with the choice again. CONCLUSION: Abortion induced with methotrexate and misoprostol appears to be a feasible alternative to surgical abortion and deserves further study.     

Minor chromosomal variants and major chromosomal anomalies in couples with recurrent abortion.

One hundred three women with prior histories of recurrent spontaneous abortion and 81 of their mates were karyotyped with Q-banding during 1976-1980. Recurrent abortion was defined as two or more spontaneous pregnancy losses; no couple with a previous malformed fetus or child was included. These cases were reviewed in order to examine the possible contributions of minor polymorphic chromosomal variants and major chromosomal abnormalities to recurrent spontaneous pregnancy loss. Balanced translocations were detected in four women and two men in the study; mosaic X aneuploidy was noted in one woman. Quantitative (1 qh, 9qh, 16qh, Yqh) and qualitative (3c, 4c, 13p, 13s, 14p, 14s, 15p, 15s, 21p, 21s, 22p, 22s) heterochromatic polymorphisms were blindly assessed and compared with a control group. Cases and controls did not differ in the frequency of any qualitative polymorphisms or in the length of any quantitative polymorphism. Thus, while major parental cytogenetic aberrations are significantly associated with fetal wastage, these data suggest that minor polymorphic chromosomal variants do not play an important role in the etiology of recurrent spontaneous abortion.     

Immunoexpression of CD30 and CD30 ligand in deciduas from spontaneous abortions

In the present study, using immunohistochemistry, we studied the expression of CD30 and CD30-L in 35 deciduas obtained from women following elective abortion during normal physiological gestation and in 60 deciduas obtained from women after spontaneous abortion with or without signs of inflammation. The main difference was noticed in the first trimester of gestation in which was found a decrease in CD30/CD30-L-positive decidual glandular and stromal cells in a greater number of cases of spontaneous abortions with respect to cases of physiological pregnancies (70% vs 50%, p<0.05). In addition, deciduas from spontaneous abortions with inflammation and without inflammation reacted similarly. The reduced expression of CD30 and CD30-L and their cellular pattern detected in the deciduas from spontaneous abortions suggest that the CD30/CD30-L system is crucial for preventing abortions in the first trimester. Furthermore, the distinctive expression of CD30/CD30-L in deciduas from physiological pregnancies may indicate that the CD30/CD30-L system exerts its main role in the first trimester.     

Pregnancies in women with and without renal scarring after urinary infections in childhood.

OBJECTIVE--To compare the outcome of pregnancy in women with and without renal scarring after childhood urinary infections with that in unmatched controls. DESIGN--Retrospective study of pregnancies in women prospectively followed up from their first recognised urinary infection. SETTING--Tertiary referral centre in Gothenburg. SUBJECTS--111 Women attending an outpatient clinic for women with urinary infection during 1975-83, of whom 41 (65 pregnancies) were studied (19 women with renal scarring (32), 22 without scarring (33)), and 65 controls (65) randomly selected and matched for parity, age, smoking habits, and date of delivery. MAIN OUTCOME MEASURES--Urinary infections and complications in pregnancy. RESULTS--The incidence of bacteriuria during first pregnancies was significantly greater in women with (9, 47%) and without (6, 27%) renal scarring after childhood urinary infection than in controls (1, 2%) (p less than 0.001, 0.01 respectively). Symptomatic infections were seen only among women with a history of urinary infection: four women with renal scarring (three of whom had vesicoureteric reflux) developed pyelonephritis and three cystitis, and one woman without scarring developed pyelonephritis. Mean blood pressure was higher among women with severe renal scarring than controls (4/11 v 3/44; p less than 0.05) before and during pregnancy. There was no significant difference in the incidence of pre-eclampsia, operative delivery, prematurity, or birth weight. CONCLUSIONS--Women with a history of previous urinary infections had a high incidence of bacteriuria during pregnancy, and those with renal scarring and persistent reflux were prone to develop acute pyelonephritis. The risk of serious complications in pregnancy, however, was not increased in women with severe renal scarring, possibly owing to their continuous clinical supervision.     

The role of dydrogesterone in recurrent (habitual) abortion

The published evidence regarding the administration of dydrogesterone in the treatment of habitual abortion is summarised in this review. Habitual abortion is defined as the loss of three or more consecutive pregnancies without known maternal or foetal pathology. The immunology of early pregnancy seems to determine the rejection or non-rejection of the allogenic embryo. When peripheral mononuclear cells from recurrent aborters are incubated with progesterone or dydrogesterone in vitro, T-helper (Th)2 cytokines such as interleukin (IL)-4 and IL-6 markedly increase whereas the Th1 cytokine interferon-γ decreases. Additionally, both progesterone and dydrogesterone are thought to inhibit the activity of natural killer cells at the foeto-maternal interface in humans. Progesterone-induced blocking factor (PIBF) mediates the immunological effects of progesterone and dydrogesterone in pregnancy. It affects various phases of the maternal immune response involving both the cellular and humoral immune system, exerts anti-abortive effects and inhibits the release of arachidonic acid. It also favours the production of so-called asymmetric, pregnancy-protecting antibodies. In rodents, blockade of this factor results in the termination of pregnancy and in women considerably lower levels are found in those with threatened abortion or pre-term labour. In order to draw final conclusions as to the usefulness of dydrogesterone in women with a history of recurrent miscarriage, further controlled, blinded, randomised clinical trials are needed.     

Changes in estrogen levels in maternal venous plasma after intra-amniotic infusion of prostaglandin F2 for therapeutic abortion

Peripheral plasma levels of estrone, estradiol-17beta and estriol were measured by the method of Shutt and Cox in 10 women following intra-amniotic infusion of prostaglandin F2alpha (PGF2a) for therapeutic abortion. Initial dose was 30 mg, followed if necessary, by doses of 15 mg at 24 hours and 42 hours. Gestational age of pregnancies ranged from 14 to 19 weeks, with a mean of 16 weeks. All 10 women completely aborted. Mean induction-abortion interval was 24 + or - 12 hours. The mean estrone, estradiol 17beta and estriol levels declined to about half of the pre-infusion levels after 80% of the induction-abortion interval had elapsed. The main decline in estrogen levels occurred in individual women either during the 1st quarter or during the last quarter of the induction-abortion interval. There were no significant relationships between changes in estrogen levels and the interval from 1st administration of PGF2a to subsequent abortion.     

Efficacy and long term effects of antenatal prophylaxis with anti-D immunoglobulin.

OBJECTIVE--To measure the safety and efficacy of antenatal treatment with anti-D immunoglobulin. DESIGN--Open study with historical controls. SETTING--Multicentre study in 17 hospitals in West Yorkshire. PATIENTS--1238 Rh negative women who delivered Rh positive infants after 34 weeks in their first pregnancy in 1980-1 (group 1) and 2000 similar primigravidas from 1978-9 (group 2). Obstetric data were collected for 616 women in group 1 who had a subsequent pregnancy, 536 similar women in group 2, and 410 Rh positive but otherwise similar primigravidas who delivered in the same hospitals in 1978-81 (group C). INTERVENTIONS--Anti-D immunoglobulin 100 micrograms intramuscularly was given at 28 and 34 weeks to the mothers in their first pregnancy who delivered in 1980-1. END POINTS--Detection of anti-D antibody in the first or any subsequent pregnancy in groups 1 and 2. For all three groups having subsequent pregnancies gestation at delivery, birth weight, fetal survival at one month, pre-eclampsia defined as blood pressure greater than 140/90 on two occasions more than 12 hours apart, and proteinuria greater than 0.25 milligram. MEASUREMENTS AND MAIN RESULTS--Antenatal immunisation to Rh(D) occurred in six mothers in group 1 and 32 group 2. Most immunisations occurred in the first or second pregnancy. The rates of abortion, gestation at delivery, birth weight, and fetal survival were not significantly different among the three groups. The incidence of pre-eclampsia was lower in mothers given antenatal anti-D immunoglobulin, but the difference was not significant. CONCLUSIONS--Antenatal prophylaxis with anti-D immunoglobulin is effective, and the effect of giving it in the first pregnancy persists into at least the second pregnancy. It seems to be safe for the fetus in the index and subsequent pregnancies.     

Perinatal outcome of pregnancies in women aged 40 and over

Perinatal outcome of pregnancies at forty and over was analyzed starting from the diagnosis of pregnancy to seven days following delivery. Retrospectively, pre-gestational health and reproduction status were dealt with, as well as the course of pregnancy, deliveries, and newborn children (study group). The control group was composed of pregnant women aged 20 to 29, who were identical to study group in terms of parity. Statistical data processing was done by means of chi2-test, and contingency 2 x 2 tables. The difference was significant if p < 0.05. Out of 2,099 diagnosed wanted pregnancies at forty and over, 415 (19.8%) had a miscarriage, in 33 (1.6%) an artificial abortion was performed after determining the fetus karyotype and 1,651 (78.2%) of pregnant women delivered. In 66.2% of pregnancies the fetus karyotype was determined and in 33 (2.5%) fetuses chromosomal abnormalities were found Incidence of deliveries at 40 and over is 1.38%, which is a 35.6-percent increase in the last ten years. Nullipara and pluripara had an increase, and multipara had a decrease. Pre-gestational health and reproduction status in study group is lower than in control group. Complications during pregnancy: threatened abortion, EPH gestosis, placenta praevia, gestational diabetes, late fetal death are more frequent than in control group (p < 0.05). In intrapartal terms, more frequent were induction of delivery, meconium-stained amniotic fluid, fetal distress, operative vaginal deliveries, and Cesarean section (p < 0.05). In neonatal outcome there are more premature infant, there are more VLBW, LBW, SGA, newborn with low Apgar index values, and the total perinatal death is greater than in the control group (p < 0.05). In perinatal terms, (from the diagnosis to the seventh day following delivery) 1,617 children survived (77.0%), meaning that perinatal loss was 482 (23.0%). Authors conclude that pregnancy at 40 and over is a high-risk pregnancy. There is a high risk of pre-gestational and gestational complications, and perinatal loss is high. Therefore, those pregnancies are not desirable from the medical point of view.     

Does the karyotype of a spontaneous abortion predict the karyotype of a subsequent abortion? Evidence from 273 women with two karyotyped spontaneous abortions.

At least two spontaneous abortions were karyotyped in 273 women during cytogenetic surveys in New York City and Honolulu. These pairs were analyzed using maximum-likelihood logistic-regression analysis to adjust for maternal age and location. There was a significantly increased risk for a chromosomally normal spontaneous abortion after a previous abortion with a normal karyotype. There was no increased risk for trisomy in a second spontaneous abortion following either a previous trisomic abortion or an abortion with another abnormal karyotype. This is unexpected, given the increased risk for trisomy found among live births and at prenatal diagnosis in young women with a previous trisomic birth. The most likely explanation is that the increased recurrence risk for trisomy is restricted to trisomy for only one or a few chromosomes, for reasons such as parental trisomy mosaicism. These data predict no increased risk of chromosome abnormality in future pregnancies after either (1) spontaneous abortions with trisomies of a kind that are always lethal in utero or (2) multiple early abortions in the presence of normal parental karyotypes.     

Treatment with a single vaginal suppository containing 15-methyl PGF2 alpha methyl ester at expected time of menstruation.

Termination of early pregnancy, by vaginal administration of prostaglandin analogues, one to three weeks after the first missed menstrual period, has advantages and disadvantages in comparison with vacuum aspiration. Some of these may be reduced if the patient is treated earlier. In the present study the effect and safety of one vaginal administration of 2.5 to 3 mg 15-methyl-PGF2 alpha methyl ester around the expected time of menstruation was evaluated in 16 women exposed to the risk of pregnancy. The overall number of treatment cycles was 35 and pregnancy was confirmed by plasma beta-HCG in eight. The treatment resulted in bleeding in all the pregnant cycles while in the nonpregnant ones it only provoked spotting and bleeding did not begin until the expected time of menstruation. Treatment with 2.5 mg 15-methyl-PGF2 alpha methyl ester resulted in complete abortion in one of three women. If the dose was increased to 3 mg all five treated women aborted. In nonpregnant patients no changes in the levels of estradiol-17 beta or progesterone at any time during the 24-hour observation period were found. Serum cortisol and prolactin but not TSH levels started to increase two hours after the start of treatment and reached a maximum after five hours. The increase coincided with the onset of uterine pain. Ovulatory cycles as judged from basal body temperature occurred in the first menstrual cycle following treatment in all nonpregnant patients. Although possible to use as a "once a month treatment" it seems preferable since the dose is the same, to postpone treatment until menstruation is delayed for a week or more.