Safety of local versus general anesthesia for second-trimester dilatation and evacuation abortion

In 1980, approximately 100,000 women underwent abortion by dilatation and evacuation between 13 and 24 weeks' gestation; an estimated 500 women experienced serious complications. The comparative safety of local versus general anesthesia for second-trimester dilatation and evacuation is unknown. To compare the serious complications (hemorrhage requiring transfusion, unintended major surgery, and a temperature of greater than or equal to 38 C for greater than three days), 4147 women who received general anesthesia and 5389 women who received local anesthesia at 13 centers in the United States from 1975 to 1978 were studied. Women who had a dilatation and evacuation abortion under general anesthesia had a relative risk of serious complications of 2.6 (95% confidence interval 1.4 to 4.9) compared with women who underwent dilatation and evacuation abortion under local anesthesia. Local anesthesia for second-trimester dilatation and evacuation appears to be both safer and less expensive than general anesthesia.

Abortions that fail

In this study of 33,090 suction curettage abortions performed at less than or equal to 12 weeks' gestation, the rate of unrecognized failed abortions was 2.3 per 1000 abortions. Women with one or more prior pregnancies and those having an abortion at less than or equal to six weeks' gestation, particularly when small suction cannulae were used, were at higher risk for this complication (relative risks of 2.2, 2.9, and 11.1, respectively). Failures were also more likely when abortions were performed by resident physicians (relative risk of 2.2) and when they were performed on women with uterine anomalies (relative risk of 90.6). Physicians can minimize the risk of failed abortion by selecting an appropriate suction cannula size and by planning the optimal time to perform the abortion. Likewise, abortions performed either by residents or on women with uterine anomalies merit extra care.

Systemic lupus erythematosus and reproductive function: a case-control study

Systemic lupus erythematosus characteristically afflicts women of reproductive age, yet the explanation for this feature is unknown. This hospital-based, case-control study of 109 incident cases of systemic lupus erythematosus and 109 randomly selected controls was conducted to search for risk factors related to reproduction. Women who were 34 years of age and younger had a crude risk of systemic lupus erythematosus 3.6 times that of older women, and women who were of minority races had a crude risk 4.8 times that of white women (P less than 0.001). Prior hysterectomy or tubal sterilization had a significant protective effect (odds ratio, 0.55; 95% confidence interval, 0.31 to 0.99). Endometriosis was associated with a twofold increased risk of systemic lupus erythematosus, although this was not statistically significant. The latter two findings are consistent with the hypothesis that retrograde menstruation may be an inciting factor for systemic lupus erythematosus in susceptible women.

The risk of serious complications from induced abortion: do personal characteristics make a difference?

We examined the age, gestational age, parity, race, and number of previous spontaneous and induced abortions of 82,030 women who obtained abortions at less than or equal to 24 weeks' gestation. Among these women, 342 (0.4%) had serious complications, including 130 (0.2%) with fever greater than or equal to 38 degrees C for 3 or more days, 172 (0.2%) who required transfusions, 67 (0.1%) who required unintended surgery, and three who died. Factors significantly (p less than 0.05) associated with serious complications varied by period of gestation, including previous induced abortions (adjusted relative risk = 1.57, 95% confidence interval = 1.03 to 2.40) for procedures done at less than or equal to 12 weeks' gestation, advancing age (relative risk for a 5-year increment = 1.12, 95% confidence interval = 1.01 to 1.24), and advancing gestational age (relative risk for a 2-week increment = 1.50, 95% confidence interval = 1.43 to 1.57) for procedures done at greater than 12 weeks, and greater than or equal to 1 previous delivery (relative risk = 1.34, 95% confidence interval = 1.03 to 1.75) for all gestational ages. Although Hispanic women had higher rates of complications compared with white women, data were not available to control for socioeconomic status in comparing race groups. There was no significant association between previous spontaneous abortions and serious complications. Risk patterns were similar, but not identical, when fever, operation, and transfusion were considered separately.

Vasopressin reduces blood loss from second-trimester dilatation and evacuation abortion

In a double-blind randomised trial, the effect of paracervical injection of vasopressin was compared with placebo on blood loss from dilatation and evacuation abortion. Vasopressin reduced blood loss significantly, an effect that became clinically more important with advancing gestational age. Blood pressure was unchanged.

Morbidity and mortality from second-trimester abortions

The comparative safety of methods used to perform second-trimester abortion is an important public health concern. Morbidity and mortality studies have indicated that dilation and evacuation (D&E) is safer than instillation abortion, which is safer than hysterotomy and hysterectomy. In the third phase of the Joint Program for the Study of Abortion, the adjusted relative risk of serious complications associated with the intraamniotic instillation of urea and prostaglandin F2 alpha (the safest abortifacient regimen) was 1.9 times that associated with D&E (95% confidence interval, 1.2-3.1). An analysis of abortion mortality in the United States from 1972 to 1981 revealed a death-to-case rate of 4.9 per 100,000 abortions associated with D&E, 9.6 with instillation methods and over 60 with hysterotomy and hysterectomy. Little information exists concerning potential late sequelae of second-trimester abortion. D&E appears to be the safest method of second-trimester abortion available in the United States.

Deaths from spontaneous abortion in the United States

Little is known about maternal deaths after spontaneous abortion. We studied 122 such deaths reported to the Centers for Disease Control from 1972 through 1980; 21 were intrauterine (contraceptive) device related. The number of non-IUD-related deaths decreased from 15 in 1972 to six in 1980; the mortality ratio (deaths per million live births) decreased from 4.6 in 1972 to 1.7 in 1980. Non-IUD-related deaths were results of infection (48%), hemorrhage (21%), embolism (11%), and other causes (20%). Risk factors for these deaths were age over 29 years, being of minority race, and unmarried status. Most deaths (58%) occurred between 12 and 19 weeks' gestation. The risk of death was much higher for abortion in the second trimester than in the first. Deaths following spontaneous abortion, although rare, do occur; older, black, and unmarried women are at higher risk.

Preventing febrile complications of suction curettage abortion

To identify risk factors for febrile complications after suction curettage abortion, we analyzed the data of 26,332 women who underwent suction curettage abortion at five participating centers in the Joint Program for the Study of Abortion, Part III, from 1975 to 1978. We defined febrile morbidity as an oral temperature of greater than or equal to 38 degrees C for 2 days or longer. The febrile morbidity rate was 0.34 per 100 abortions. We performed a multivariate analysis using a linear logistic regression model. Prophylactic antibiotics proved to be the most protective factor, reducing the rate of febrile complications to about one third that of women who received no prophylactic antibiotics (relative risk 0.36; 95% confidence interval 0.18 to 0.70). Patients who had had one or more previous births also had a significantly lower risk of febrile morbidity (relative risk 0.54; 95% confidence interval 0.33 to 0.88). Other factors did not significantly affect the febrile complication rate.

Causes of maternal mortality in the United States

Among 2475 maternal deaths that occurred in the United States from 1974 to 1978, 408 were related to pregnancies with abortive outcomes, and 2067 were related to other causes. Ectopic pregnancy was the most frequent cause of death in the former group. Embolism, hypertensive disease of pregnancy, obstetric hemorrhage, and obstetric infection were the most common causes of death in the latter group. Women who were 30 years of age or older or of minority race were at increased risk of death. Nationwide surveillance of maternal mortality is feasible and should help to increase the safety of childbearing.

Perinatal and maternal mortality in a religious group avoiding obstetric care

We investigated perinatal and maternal deaths occurring among women who were members of a religious group in Indiana; these women received no prenatal care and gave birth at home without trained attendants. Members of the religious group had a perinatal mortality rate three times higher and a maternal mortality rate about 100 times higher than the statewide rates. These findings suggest that, even in the United States, women who avoid obstetric care have a greatly increased risk of perinatal and maternal death.

Prophylactic antibiotics for curettage abortion

Opinion is divided as to the advisability of routine use of prophylactic antibiotics for curettage abortion. Six studies, including three randomized clinical trials, suggest that prophylaxis reduces infectious morbidity associated with curettage abortions by about one half. Three other studies, two involving prophylaxis for instillation abortions and one involving a vaginal antiseptic for curettage abortion, support the hypothesis that antimicrobial prophylaxis reduces morbidity. Tetracyclines are commonly used for this purpose. The cost of routine prophylaxis even with an expensive tetracycline would appear to be offset by the savings in direct and indirect costs. Prophylaxis may help prevent both short-term morbidity and potential late sequelae, such as ectopic pregnancy and infertility.

Second-trimester abortions in the United States

Late abortion remains a complex and difficult issue in the United States, where about 10 percent of all abortions are performed at 13 or more weeks' gestation. The reasons why women delay having abortions appear to be largely personal, and most are not amenable to public health intervention. Dilatation and evacuation (D&E) is the most frequently used method of second-trimester abortion, and the safest. Its greatest safety advantage lies in the 13-16-week-interval; for later abortions, D&E and instillation abortion have similar risks of complications and death. The rare instances in which an abortion procedure ends in a live birth represent the most controversial aspect of second-trimester abortion. However, trends toward abortions at earlier gestational ages, use of D&E and increased reliance on ultrasonography to confirm gestational age should reduce the frequency with which such events occur. Research in the area of midtrimester abortion should seek ways to reduce the need for such procedures, to improve their safety and to minimize the trauma of the experience for women.

Epidemiology of gestational trophoblastic disease

The epidemiology of gestational trophoblastic disease is not well understood. Methodologic problems with published reports limit the interpretation of incidence data, although the frequency of hydatidiform mole appears to be about one per 1000 pregnancies. No consistent temporal trends in rates of either hydatidiform mole or choriocarcinoma are evident. Hydatidiform mole appears to be caused by abnormal gametogenesis and fertilization. Age, ethnicity, and a history of hydatidiform mole appear to be important risk factors for hydatidiform mole. Age, ethnicity, a history of hydatidiform mole or fetal wastage, and ABO blood group interactions appear to be important risk factors for choriocarcinoma. Future studies should focus on the mechanisms by which these risk factors influence gametogenesis, fertilization, and malignant transformation of trophoblastic tissue.

Maternal deaths in the United States by size of hospital

There is growing interest in the relationship between hospital size and the comparative safety of childbearing. Using death certificates received from each state health department for 1974 to 1978 and data provided by the American Hospital Association, national maternal mortality rates were calculated by hospital size (number of inpatient beds) and size of hospital obstetric service (annual number of live births). The smallest and largest hospitals had higher rates of maternal mortality than intermediate-size hospitals. These findings may have implications for improving the safety of childbearing in the United States.

Ectopic pregnancy mortality, United States, 1979 to 1980: clinical aspects

Ectopic pregnancy has recently become a major cause of maternal mortality in the United States. Despite its increasing public health impact, relatively little is known about the clinical epidemiology of this condition. Therefore, the authors investigated all reported deaths from ectopic pregnancy in the United States occurring in 1979 and 1980, to determine characteristics of, and risk factors for, fatal ectopic pregnancy. Most women (85%) died from hemorrhage. Abdominal and interstitial implantations were more likely to become symptomatic later in gestation and to be fatal than were tubal implantations. Of those deaths for which circumstances were known, more prompt diagnosis and treatment of ectopic pregnancy by health professionals might have prevented one-half of the deaths. One-third of the deaths might have been prevented if the women had notified or visited a physician more promptly after the onset of symptoms. Timelier action by women and health professionals could reduce ectopic pregnancy mortality.

Legal abortion and placenta previa

Legal abortion has been postulated to be a risk factor for placenta previa in subsequent pregnancies. To examine this hypothesis, we analyzed the deliveries of 28,665 women. We identified 68 women who had had placenta previa and compared their obstetric histories with those of 68 controls randomly selected from the same group of deliveries. The crude risk ratio for women with a history of one or more legal abortions was 1.4 (95% confidence interval, 0.5 to 3.6; p greater than 0.05). Standardizing the crude risk ratio for the effects of age and gravidity reduced the risk ratio to 1.1 (95% confidence interval, 0.4 to 2.8). In this predominantly black population legal abortion does not appear to have a significant association with placenta previa in subsequent pregnancies.

Prevention of uterine perforation during curettage abortion

Although uterine perforation is a potentially life-threatening complication of curettage abortion, little is known about the risk factors associated with uterine perforation or how to prevent it. Using linear logistic regression, we analyzed 67,175 curettage abortions performed at 13 institutions in the United States from 1975 through 1978. The overall incidence of confirmed perforation was 0.9 per 1,000 abortions. Performance of the abortion by a resident rather than by an attending physician was a powerful risk factor for perforation (relative risk, 5.5; 95% confidence interval, 3.3 to 9.2). Use of Laminaria for dilation had a protective effect, although this effect was not statistically significant (relative risk, 0.17; 95% confidence interval, 0.02 to 1.2). Among factors beyond the control of the physician, advancement of gestational age and previous delivery were significant risk factors. Use of Laminaria and performance of the abortion by an attending physician considerably lowered the risk of uterine perforation.

Hysterectomy as treatment for complications of legal abortion

The frequency of hysterectomy as treatment for abortion complications may reflect the incidence of serious abortion morbidity. To examine this use of hysterectomy, the authors analyzed reports of approximately 237,000 legal abortions performed in the United States from 1970 to 1978. Overall, the rate of hysterectomy associated with curettage abortion decreased from 4.6 per 10,000 abortions in 1970 to 1971 to 1.4 per 10,000 in 1975 to 1978; the rate of hysterectomy associated with instillation abortion fell from 6.8 to 4.3 per 10,000 for the same years. A history of older age, previous births, use of instillation abortion, and preexisting gynecologic disorders increased the likelihood of hysterectomy. In cases of curettage abortion, hysterectomy rates increased significantly with advancing gestational age. Changes in abortion technology, improvements in physician skill, and more conservative management of complications have likely contributed to the decreasing frequency of hysterectomy necessitated by abortion complications.

Midtrimester abortion. Intra-amniotic instillation of hyperosmolar urea and prostaglandin F2 alpha v dilatation and evacuation

Although dilatation and evacuation (D&E) is currently the most common method of midtrimester abortion in the United States, the intra-amniotic instillation of hyperosmolar urea and prostaglandin F2 alpha combined (U-P) has been proposed as a safer technique. To evaluate the comparative safety of U-P and D&E, we analyzed 2,805 U-P and 9,572 D&E abortions at 13 to 24 menstrual weeks' gestation. The U-P procedure resulted in significantly more serious complications than D&E (1.03 v 0.49 per 100 abortions). After adjusting for patient age, race, parity, follow-up information, and preexisting conditions, the relative risk of serious complications associated with U-P was 1.9 (95% confidence interval, 1.2 to 3.1). This advantage for D&E stems from its applicability to the 13- to 16-week interval. Although D&E appears to be safer overall in the midtrimester, for women obtaining abortion after 16 weeks, the rates of serious complications were comparable, with a relative risk of 1.0 (95% confidence interval, 0.4 to 2.5).

The question of a helminthic cause of preeclampsia

Two recent reports have suggested that wormlike structures characteristic of helminths are associated with preeclampsia. We identified these vermiform structures in toluidine blue O-stained venous blood smears from four women with preeclampsia, cord blood taken at delivery of three of their neonates, and venous blood from five control subjects without preeclampsia and from five healthy beagle dogs. The structures, which had diameters between 30 and 670 microns, could not be concentrated by passing the blood through a 12-microns filter, yet they could be demonstrated in stained smears prepared from blood that had been filtered. We conclude that these structures are not helminths; they are most likely artifacts of staining.

Fatal hemorrhage from legal abortion in the United States

Deaths from hemorrhage associated with legal induced abortion should not occur. Yet hemorrhage was the third most frequent cause of death from legal abortion in the United States between 1972 and 1979. This study was undertaken to document the scope of the problem, to identify risk factors for fatal hemorrhage and to recommend ways of preventing these deaths. Deaths were identified through the CDC's nationwide surveillance of deaths from abortions; information on numbers and characteristics of women having legal abortions was obtained from CDC and the Alan Guttmacher Institute. Twenty-four women died from hemorrhage after legal abortion in the United States from 1972 to 1979, for a death-to-case rate of 0.3 deaths per 100,000 abortions (95 per cent confidence interval 0.2 to 0.5). Women who died from hemorrhage were significantly older than those who died from other causes (27.6 versus 24.4 years; p less than 0.05). Documented uterine perforation or rupture was far more frequent among women who died from hemorrhage than those who died from other causes (71 versus 8 per cent; p less than 0.001). Women who sustained uterine perforation or rupture were over 1,000 times more likely to die from hemorrhage than those who did not. Deaths from hemorrhage can be eliminated by preventing uterine trauma during abortion and by rapidly diagnosing and treating hemorrhage if it occurs.