The risks associated with teenage abortion

the risks of morbidity and mortality affect a teenager's choice between termination of a pregnancy through induced abortion and continuation of the pregnancy. To identify these risks, we analyzed information from two separate sets of data collected by the Centers for Disease Control: that of the Joint Program for the Study of Abortion, a multicenter prospective study of nearly 165,000 legally induced abortions; and that of a national surveillance of abortion-related mortality. The rates of major complications associated with abortions in teenagers were 1 to 3 per 1000 suction-curettage procedures and approximately 13 per 1000 saline-administration procedures. The death-to-case rate for teenage women was 1.3 per 100,000 procedures. When the data on procedures were adjusted according to gestational age, teenagers generally had lower rates of morbidity and mortality from induced abortion than older women.

Urea-prostaglandin versus hypertonic saline for instillation abortion

Authorities have suggested use of a combination of hyperosmolar urea and low-dose prostaglandin F2 alpha as a second-trimester intra-amniotic abortifacient to avoid the disadvantages of hypertonic saline solution. To examine the safety and efficacy of urea-prostaglandin compared with the instillation of saline solution, we analyzed data from a prospective multicenter study conducted in the United States between 1975 and 1978. Both agents were highly effective in producing an abortion. However, urea-prostaglandin had a significantly lower rate of serious complications when compared with saline solution (1.03 versus 2.18 per 100 abortions; p less than 0.001). Urea-prostaglandin also had a significantly shorter induction-to-abortion time (14.2 versus 25.6 hours; p less than 0.001). Urea-prostaglandin, therefore, appears to be superior to hypertonic saline solution as an abortifacient.

Hysterectomy in the United States

Hysterectomy is the most frequently performed major operation in the United States--and one of the most controversial. Although there are large regional differences in hysterectomy rates, the nationwide rate declined between 1975 and 1980. Leiomyomas, dysfunctional uterine bleeding, and pelvic relaxation are among the most frequent indications for hysterectomy. One fourth to one half of all women who undergo hysterectomy develop some morbidity, with fever and hemorrhage the most common types. Late sequelae may include the residual ovary syndrome, depression, and an increased risk of cardiovascular disease. The mortality rate appears to be about one death per 1000 operations. Neither prevention of cancer nor contraceptive sterilization appears to justify elective hysterectomy in asymptomatic women. Hysterectomy will continue to be an important component of women's health care. Ongoing peer review activities, improvements in surgical technique, and continued research should help ensure that each hysterectomy performed is both appropriate and safe.

Maternal deaths associated with antepartum fetal death in utero, United States, 1972 to 1978

Little is known about the overall incidence of fetal death in utero (FDIU) in the United States or about the risks associated with its management. To address these questions, this study provides nationwide incidence data and reviews nine deaths of women with FDIU in the United States from 1972 to 1978. The crude death-to-case rate associated with FDIU is at least 4.5 deaths per 100,000 cases (95% confidence limits, 2.1 to 8.5). Existing information from comparative studies is inadequate to evaluate the comparative safety of different methods of evacuating the uterus after FDIU occurs at different gestational ages. Management of such cases should be determined by both the experience of the physician with uterine evacuation techniques and the medical and psychologic needs of the woman.

Rh immunoglobulin use with placenta previa and abruptio placentae

Patients with obstetric hemorrhage from placenta previa or abruptio placentae may be at increased risk of Rh sensitization because they fail to receive Rh immunoglobulin (RhIG) or are given an inadequate dose. To evaluate the use of RhIG in this clinical situation, we studied 498 patients with hemorrhage from placenta previa or abruptio placentae treated at a large municipal hospital from 1975 to 1979. All 25 RhIG candidates received the product before their discharge from the hospital. This rate of RhIG use was equal to that for patients whose infants were delivered without these complications and significantly higher than that for patients with spontaneous abortion and ectopic pregnancy at the same hospital (P less than .05). Prompt administration of an adequate dose of RhIG to candidates with bleeding from placenta previa or abruptio placentae can further reduce Rh hemolytic disease.

Measures to prevent cervical injury during suction curettage abortion

Cervical injury is one of the most frequent complications of suction curettage abortion, yet little is known about its risk factors or prevention. In 15 438 suction curettage abortions carried out at less than or equal to 12 weeks' gestation in hospitals in the USA from 1975 to 1978 the incidence of cervical injury requiring suturing was 1.03 per 100 abortions. Among factors potentially within the physician's control, use of laminaria rather than rigid dilators for dilatation had a strong protective effect (relative risk 0.19), whereas performance of the abortion by a resident rather than an attending physician (relative risk 2.0) and use of general rather than local anaesthesia (relative risk 2.6) had detrimental effects on rates of cervical injury. Among other factors, a previous abortion had a protective effect (relative risk 0.46), whereas patient age less than or equal to 17 years had a detrimental effect (relative risk 1.9). Use of laminaria, performance of the abortion by an attending physician, and local anaesthesia together yield a 27-fold protective effect.

Third-trimester induced abortion in Georgia, 1979 and 1980

We reviewed 86 third-trimester induced abortions reported to the Georgia Department of Human Resources in 1979 and 1980. Only three of the 78 with adequate data were classified correctly. Fetal deaths in utero accounted for 67.4 per cent of reported cases and first- or second-trimester abortions 18.6 per cent. The true rate of induced abortions performed in the third trimester was 4.3 per 100,000 legal abortions. Diagnosed anencephaly accounted for two out of the three valid third-trimester induced abortions performed.

Comparative safety of the low transverse versus the low vertical uterine incision for cesarean delivery of breech infants

Little is known about the comparative safety of the low transverse versus the low vertical uterine incision for cesarean delivery of singleton infants in breech presentation. To address this question, the short-term maternal and infant complications of 221 breech deliveries by low transverse incision and 195 by low vertical incision were analyzed. The perinatal mortality rate associated with the low transverse incision was significantly lower than that associated with the low vertical incision (41 versus 92 deaths per 1000 births; P less than .05). When standardized for birth weight or gestational age, the difference was no longer statistically significant (P greater than .05). The incidences of an Apgar score of 6 or lower, extension of the uterine incision, a decrease in hematocrit by 6 points or more, blood transfusion, and maternal fever were not significantly different. Since these types of incisions appear to have comparable safety, the possibility of a vaginal delivery with later pregnancies suggests that the low transverse uterine incision is preferable to the low vertical incision.

Diagnostic endometrial aspiration with the Karman cannula

Endometrial aspiration with the Karman cannula can be used to detect endometrial pathology. To document the feasibility and accuracy of endometrial aspiration with this cannula, 49 women were evaluated by this technique prior to diagnostic dilation and curettage (D&C). Completion rates for both endometrial aspiration and D&C were 96%. Endometrial aspiration yielded tissue adequate for histologic evaluation in 82% of cases as compared with 76% of D&C cases. Three cases of cancer (two endometrial and one endocervical) were identified by both techniques. A majority of patients expressed a preference for endometrial aspiration over D&C. Endometrial aspiration with the Karman cannula appears to be a convenient, accurate and acceptable method of detecting endometrial pathology.

Reducing classification errors in cohort studies: the approach and a practical application

Classification errors of dependent variables can distort the results of observational studies. To reduce misclassification from our multicentre observational study of abortion complications, we extended the methodology of Lawrence and Greenwald for use in situations of unequal sample sizes and implemented both an office review and a field review. We reabstracted 424 reported complications and a random sample of 364 reported non-serious cases from 12 institutions participating in our study. In total, 30 per cent of the reported serious complications turned out to be misclassified: the office review detected 74 per cent of the total number of misclassifications with the remainder found in the field review. Because, with our particular data base, we estimated expending only 15 per cent of the total resources with our office effort, this represented the most cost-efficient approach to reducing classification errors. By eliminating the false positives from our study, we forced the specificity to 1.00 which produced both an unbiased estimate of the relative risk and an increase of 4 per cent to 63 per cent in the power of our study.

Deaths from contraceptive sterilization in bangladesh: rates, causes, and prevention

This report summarizes the second of 2 epidemiologic investigations of deaths attributable to sterilization in Bangladesh. All deaths resulting from sterilizations performed nationwide between September 16, 1980, and April 15, 1981, were investigated and analyzed. Nineteen deaths from tubal sterilization were attributed to 153,032 sterilization operations (both tubal sterilization and vasectomy), for an overall death-to-case rate of 12.4 deaths per 100,000 operations. This rate is lower than that (21.3) for operations performed in Dacca and Rajshahi Divisions from January 1, 1979, to March 31, 1980, although this difference is not statistically significant. Anesthesia overdosage, tetanus, and hemorrhage were the leading causes of death. Improvements in anesthesia management, surgical asepsis, and postoperative monitoring of vital signs should make sterilization operations even safer. Although tubal sterilizations performed in Bangladesh cost some lives, they avert far more maternal deaths. The net health impact is strongly favorable: For every 100,00 tubal sterilizations performed, approximately 100 deaths are prevented.

Dilatation and evacuation procedures and second-trimester abortions. The role of physician skill and hospital setting

Some clinicians have hesitated to perform dilatation and evacuation (D & E) procedures at 13 weeks' gestation or later because D & Es are more difficult to perform safely than suction-curettage procedures. Moreover, many clinicians still believe all second-trimester abortion procedures should be performed in a hospital. To evaluate these concerns, we analyzed 24,664 abortion performed between 1973 and 1978 by four physicians associated with a large outpatient abortion facility; 3,711 (15%) of the abortions were second-trimester procedures. Dilatation and evacuation was associated with a lower rate of serious complications per 100 procedures (0.23) than instillation of either dinoprost (prostaglandin F2 alpha) (1.28) or hypertonic saline (2.26). In addition, D & E had lower rates for most other specific complications. We conclude that D & E, while requiring more operator skill than earlier suction-curettage procedures, can be learned by gynecologists familiar with suction-curettage, can be performed more safely than the alternative instillation procedures, and can be safely practiced in selected ambulatory settings.

Mortality from abortion and childbirth. Are the statistics biased?

Critics have challenged previous comparisons of mortality from legal abortion and childbirth for containing biases in the crude data that spuriously favor the safety of abortion. To evaluate this concern, we reviewed the sources of mortality data on which these comparisons are based and examined the completeness of abortion mortality statistics, the completeness of childbirth mortality statistics, and the accuracy of the denominators for both these events. We found the evidence to be consistent in two directions: (1) abortion deaths appear to be more completely ascertained than childbirth deaths; (2) use of different denominator estimates has relatively little impact on the comparison. From this evidence, we conclude that the crude data are biased in a direction that overestimates the abortion risks for the women relative to the risks of childbearing.

Mortality from abortion and childbirth. Are the populations comparable?

Critics have challenged previous comparisons of mortality from legal abortion and childbirth for contrasting population groups with different clinical characteristics. They allege that most women dying from abortion were young, white, and healthy, while those dying from childbirth had serious underlying conditions. To address this question, we calculated standardized abortion and childbirth mortality rates between 1972 and 1978. We also adjusted independently for preexisting medical conditions. These adjustments for demographic and health differences between the two populations actually widened the difference in the mortality risk between abortion and childbirth. Thus, between 1972 and 1978, women were about seven times more likely to die from childbirth than from legal abortion, with the gap increasing in the more recent years.

Sterilization-attributable deaths in bangladesh

From January 1, 1979, to March 31, 1980, 20 sterilization-attributable deaths were identified in Dacca and Rajshahi Divisions, Bangladesh. The leading cause of death from tubectomy was anesthesia overdose and from vasectomy, scrotal infection. Overall. The sterilization-attributable death-to-case rate was 21.3 deaths/100,000 procedures. The health impact of contraceptive sterilization is highly favorable: for each 100,000 tubectomies performed, the cost in lives (19) is offset by approximately 1015 maternal deaths averted.

The risk of death from combined abortion-sterilization procedures: can hysterotomy or hysterectomy be justified?

Clinicians have debated whether women who request permanent sterilization when they undergo elective abortion should have the two operations done concurrently. Moreover, if the procedures are performed concurrently, the appropriate surgical approach is unknown. To evaluate the latter issue, we identified all concurrent abortion-sterilization deaths in the United States in the period 1972 to 1978 from the Centers for Disease Control's nationwide surveillance of abortion mortality and divided them into two groups: those who had hysterotomy with tubal ligation or hysterectomy (H/H) and those who had curettage or instillation procedures, with tubal ligation by laparoscopy or laparotomy (other procedures). We then used data from the Joint Program for the Study of Abortion (JPSA/CDC) to estimate the number of procedures done in the United States in the period 1972 to 1978 and calculated death-to-case rates for each group. We found that the risk of dying from a concurrent abortion-sterilization procedure was 3.3 times higher if done by H/H. The relative risk for this group was highest during the first 12 weeks of gestation (4.6) and lowest at 13 weeks or later (1.3), regardless of the presence or absence of preexisting medical conditions. Except in the rare instances where the woman has an indication for hysterectomy other than fertility control, the performance of hysterectomy or hysterectomy for concurrent abortion-sterilization, particularly at less than 13 weeks' gestation, does not appear justified.

Diagnostic dilation and curettage: a reappraisal

Diagnostic dilation and curettage (D & C) is widely considered to be the method of choice for obtaining samples of endometrium for histologic examination, although the scientific basis for this assumption is elusive. Despite extensive use of D & C, the tissue yield and diagnostic accuracy of this technique have not been adequately evaluated. More is known about these features of a newer diagnostic procedure, Vabra aspiration (VA). VA also appears to be safer, less expensive, and more convenient than D & C. Until the alleged benefits of diagnostic D & C can be shown to outweigh its risks and costs (approaching one billion dollars per year in the United States alone), D & C probably should not be the primary procedure used for obtaining most samples of endometrium.

Comparative risk of death from induced abortion at less than or equal to 12 weeks' gestation performed with local versus general anesthesia

Although complications of anesthesia are now the leading cause of death from abortion at less than or equal to 12 weeks' gestation, the comparative risk of death from abortions performed with local versus general anesthesia is unknown. To estimate this risk for both anesthesia-related and nonanesthesia-related legal abortion deaths at less than or equal to 12 weeks' gestation, we used 1972-1977 data from the Center for Disease Control and the Alan Guttmacher Institute. When adjusted for preexisting disease and concurrent sterilization, the death-to-case rate for abortions at less than or equal to 12 weeks' gestation associated with general anesthesia was 0.37/100,000 abortions, and the rate with local anesthesia was 0.15/100,000. For nonanesthesia-related deaths, the comparable adjusted rates were 0.49 and 0.28, respectively. Use of general anesthesia is associated with a twofold to fourfold increased risk of death from abortion at less than or equal to 12 weeks' gestation.

Nongonococcal pelvic inflammatory disease

Nongonococcal PID remains a major concern in gynecology and an important public health problem. Although debate continues as to the etiologic role of nongonococcal organisms in acute PID, anaerobic and aerobic bacteria, C. trachomatis, and mycoplasmas have all been implicated. Actinomycotic PID is uniquely related to IUD use. The optimal treatment for nongonococcal PID is unknown, but tetracycline and its derivatives are effective against a broad spectrum of nongonococcal organisms. Abscesses and infertility, in particular, are serious complications of nongonococcal PID. While evolving knowledge about the polymicrobial etiology of acute PID has challenged traditional concepts, continued research should clarify the epidemiology, treatment, and prevention of this important disease.

Pregnancy outcomes in black women aged 35 and older

Pregnancy outcomes of women 35 years of age or older are considered to be less favorable than those of younger women. To examine this hypothesis, the records of 26,795 deliveries of black women at Grady Memorial Hospital from 1973 to 1978 were analyzed. Infants of 788 women who were 35 or older had a perinatal mortality rate 1.7 times higher than did infants of younger women (47 versus 28 deaths per 1000 births; P less than .01). There was no difference, however, when women with preexisting hypertension were excluded from analysis. The incidence of primary cesarean section was significantly higher for women 46 or older (17% versus 10%; P less than .001), although incidences of infants with low birth weight, low Apgar scores, and maternal infections were not significantly different. Hypertension was a more important determinant of perinatal survival than was maternal age. Age alone did not appear to be an important obstetric risk factor for healthy women 35 years of age or older.

Fatal amniotic fluid embolism during legally induced abortion, United States, 1972 to 1978

Amniotic fluid embolism (AFE) has emerged as an important cause of death from legally induced abortion. In the period 1972-1978, 12 probably and three autopsy-confirmed cases of fatal AFE during legally induced abortion were identified in the United States (12% of all deaths from legal abortion). Fourteen deaths from AFE were associated with labor-inducing techniques, and one with hysterotomy. The risk of death appears to be related to gestational age: the death-to-case rate for AFE increases progressively from nil at less than or equal to 12 weeks' gestation to 7.2 deaths per 100,000 abortions at greater than or equal to 21 weeks' gestation. Because treatment is frequently ineffective, prevention of AFE is critical. Performing abortions early in pregnancy and using curettage techniques whenever feasible should reduce the risk of death from this obstetric accident during legally induced abortion.

Deaths from second trimester abortion by dilatation and evacuation: causes, prevention, facilities

In 1978, dilatation and evacuation (D & E) became the leading method of abortion at 13 weeks' gestation or later in the United States. The increasing popularity of D & E reflects its relative advantages in safety, convenience, expense, and speed when compared with alternate methods. The authors reviewed all reported deaths from D & E in the United States between January 1, 1972, and December 31, 1978. The predominant causes of death were infection and hemorrhage. both race and gestational age significantly influence the death:case rate for D & E procedures. White women had a threefold lower risk of dying from D & E than women of other races. D & E procedures performed at 13 to 15 weeks' gestation were nearly 3 times safer than those performed at 16 weeks or later. D & E performed in nonhospital settings did not have higher death:case rates than those performed in hospitals. Comparative mortality data suggest abortion by D & E at 13 weeks' gestation or later is more dangerous than suction curettage performed earlier in gestation, but safer than instillation techniques performed later. The advantage of D & E occurs largely in the 13- to 15-week gestation interval, that is, at the beginning of the second trimester. Policy makers should reconsider laws requiring all second trimester abortions to be performed in hospitals. Based on these data, 16 weeks' gestation would be more appropriate threshold at present.

Rh immunoglobulin utilization after ectopic pregnancy

To assess the use of Rh immunoglobulin (RhIG) after ectopic pregnancy, we reviewed the charts of 305 patients treated from 1975 through 1978 at a large metropolitan hospital. We compared these patients with 389 who had had spontaneous abortions and been treated at the same hospital in 1975. The rate of ascertainment of Rh type was significantly higher for the group with ectopic pregnancy than for the group with spontaneous abortion (98.4% versus 95.1%; p less than 0.05). Nevertheless, presumable fertile RhIG candidates after ectopic pregnancy were 3.3 times more likely not to receive RhIG than candidates after spontaneous abortion (64.3% versus 19.4%;; p less than 0.01). Patients with ectopic pregnancy are an important part of the "RhIG utilization gap"; the mechanism for providing prophylaxis for patients needs to be improved.