Int J Gynaecol Obstet 15: 258-261, 1977
Laparoscopic Sterilization After 4 ' Spontaneous" Abortion Angel Quan1, Delfina de Badia 1 , David A. Edelman2, and Alfredo Goldsmith2 1
University of El Salvador School of Medicine, San Salvador, El Salvador International Fertility Research Program, Research Triangle Park, North Carolina, USA
2
ABSTRACT Quan, A., de Badia, D., Edelman, D. A. and Goldsmith, A. (University of El Salvador School of Medicine, San Salvador, El Salvador, and the International Fertility Research Program, Research Triangle Park, North Carolina, USA). Laparoscopic sterilization after "spontaneous" abortion. Int J Gynaecol Obstet 15: 258-261, 1977 One hundred eighty-nine patients were evaluated to assess the safety of laparoscopic sterilization after completion of a "spontaneous" abortion by curettage. Some of the "spontaneous" abortions had probably been illegally initiated outside the hospital and were septic. The laparoscopic sterilization procedures used tubal rings to achieve tubal occlusion. They were performed 4 to 48 hours after completion of the abortion. Patients were discharged from the hospital on the day the procedure was performed. Surgical difficulties and complications associated with the laparoscopy were infrequent. Undergoing a curettage prior to sterilization with tubal rings by laparoscopy did not appear to result in increased rates of complications.
INTRODUCTION The lowering of the age/parity requirements for sterilization and the introduction of laparoscopic methods at the Maternity Hospital of El Salvador in 1972 have resulted in a continual increase in the demand for sterilization services. From 1956 to 1965, 2 879 sterilization procedures were performed; in contrast, from 1973 to 1975 more than 12 000 procedures were performed (10). In the past year, about 72.0% of the sterilizations were performed after vaginal term deliveries; 9.0% were performed after a cesarean section; 17.0% were interval procedures; and 1.3% were performed after completion of inevitable or incomplete abortions. Various reports document the safety of interval laparoscopic sterilization (9,12,13), and others have shown that the rates of complications or surgical difficulties associated with laparoscopic sterilization after induced abortion are not significantly higher than for interval procedures (2, 3). However, no studies have reported on the safety of sterilization after inevitable or incomplete abortions, particularly after septic abortions. This study was undertaken to evaluate the safety of performing laparoscopic sterilization either immediately or soon Int J Gynaecol Obstet 15
after curettage for inevitable or incomplete abortions, including some septic abortions. METHODS AND MATERIALS From May 1975 to May 1976, 189 women, admitted to the Maternity Hospital of El Salvador for treatment of an inevitable or incomplete abortion, underwent a curettage followed by laparoscopic sterilization with tubal rings for tubal occlusion before they were discharged from the hospital Abortion procedures Unless a prolonged hospitalization was necessary for the treatment of abortion-related complications, women were usually discharged from the hospital on the same day or on the first postoperative day. Most abortions were probably not spontaneous but were illegally initiated outside of the hospital by inserting a rubber catheter into the uterus. On admission, 10.1% of the patients were classified as having a septic abortion. They usually had a fever of over 38°C, and the attending physician judged the sepsis to be confined to the uterus. Patients with a septic abortion were treated with antibiotics before undergoing dilatation and curettage (D&C). Sterilization procedures Sterilization was performed 4 to 48 hours after curettage depending on the time of day the abortion was treated, on the availability of the operating room, and on the status of the patient. No patient was scheduled for laparoscopy until she was afebrile. All procedures were single p u n c t u r e laparoscopics, performed under neuroleptanalgesia and local anesthesia. Half an hour before surgery, the patient was requested to urinate and 0.5 mg of atropine was administered intramuscularly. Prior to surgery 1 cc Thalamonal (Janssen Pharmaceutica brand of fentanyl citrate 0.05 mg and droperidol 2.5 mg per cc), followed by 50 mg meperidine and 5 mg diazepam, were administered intravenously in the operating room. The patient's abdomen was washed
Postabortion
with Betadine (Purdue Frederick Co. brand of povidone-iodine) and 20 cc 2% lidocaine was injected immediately below and around the umbilicus. Pneumoperitoneum was achieved with about 2 liters of C0 2 . Tubal occlusion was effected by applying tubal rings with a specially designed laparoscope (Fig. 1). This laparoscope consists of a standard laparoscopic lens system, a fiber-optic light source, and a ring applicator system consisting of two cylinders and a retractable grasping forceps within the inner cylinder (Fig. 2). The tubal ring (2.5 mm thick, with a 1 mm inner diameter and a 4 mm outer diameter) is fitted over the outer surface of the inner cylinder. After the Fallopian tube is identified, it is grasped at its isthmic portion with the forceps and retracted into the inner cylinder of the laparoscope. By sliding the inner cylinder within the outer cylinder of the applicator, the tubal ring is pushed off the inner cylinder and over the loop of Fallopian tube contained within the inner cylinder. The grasping forceps is then moved forward to release the loop of occluded tube. The same procedure is performed on the opposite tube. After the procedure was completed, the patients were discharged to the recovery area and observed for 2 hours before they were discharged from the hospital. Each patient was instructed to return to the hospital for a history and a physical examination at 3 weeks and at 6 and 12 months after sterilization. Subjects All but one patient reported at least one prior abortion. The median age and median parity of the patients were 31.4 years and 4.6 live births. Most patients (56.6%) were 30 to 39 years of age and were grand multiparas (50.5%) (Table I). All women had at least one living child. Three to 12 weeks after the sterilization, 84.7% returned for the scheduled follow-up visit. To date, 45.0% have been followed up for more than 6 months.
laparoscopic
sterilization
259
Fig. 2. Close-up view of the distal end of the tubal ring applicator showing the grasping forceps in the extended position and the tubal ring fitted over the inner cylinder.
RESULTS Surgical difficulties occurred during six (3.2%) of the sterilization procedures. The surgeon had difficulty visualizing the tubes as a result of an enlarged uterus in four cases. The tubes could not be mobilized easily because of adhesions between the tubes and other pelvic structures in two patients. Complications were infrequent and occurred for six patients (3.2%): tears of the tube in four cases; emphysema of the abdominal wall in one case; tuboovarian abscess in one case. For the four patients in whom the tube was inadvertently transected by Table I. Age and parity distributions
No. Age (years) 20-29 30-39 40 or more AAedian
69 107 13
Parity 1-2 3-4 5-6 7 or more AAedian
18 75 38 57
36.5 56.6 6.9 31.4 9.6 39.9 20.2 30.3 4.6
Fig. 1. Single-incision laparoscope used to apply tubal rings (manufactured by KLI, Inc., Ivyland, Penn., USA).
Int J Gynaecol Obstet 15
260 A. Quan et al
tearing the tube, the tube was occluded by applying a tubal ring to each end of the transected tube. In one patient, a 38-year-old para 6-0-1-6, laparoscopy revealed an edematous left tube. The right tube was even more edematous and was immobile because of adhesions. A tubal ring was applied to the left tube, but electrocoagulation was elected for the right tube. The patient was readmitted to the hospital 2 weeks later with fever. She developed a tubo-ovarian abscess and underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy 23 days after the sterilization. This patient was probably admitted to the hospital with occult sepsis in which the infection had already spread to the right tube and ovary. However, the diagnosis of a septic abortion was not made at the time she was admitted to the hospital. All patients were discharged from the hospital on the day the sterilization procedure was performed, except for two who were hospitalized overnight for their convenience. Only the one patient with a tuboovarian abscess was rehospitalized for treatment of a complication. To date, no pregnancies have been reported, and 85 patients have been followed up for 6 or more months.
COMMENT Laparoscopic sterilization with tubal rings, performed immediately after treatment of an inevitable or incomplete abortion, apparently poses no higher risk of complications or surgical difficulties than interval laparoscopy. The overall complication rate (3.2%) in this study is similar to that reported by other investigators using tubal rings, electrocoagulation, or spring-loaded clips for tubal occlusion at laparoscopy (1, 7, 8). In this study the most frequent complications, transection/tears of the Fallopian tubes, occurred in four cases (2.1%), usually when the Fallopian tube was retracted into the inner cylinder of the laparoscope. The rate is similar to the rate reported by other investigators (6). Difficulty in retracting the tube may be more likely for patients with edematous tubes because the inside diameter of the inner cylinder is only 4.7 mm. This difficulty, which may be more frequent among postabortion patients, only occasionally results in tears of the Fallopian tubes. Although the staff and facilities may be used more efficiently when laparoscopy is performed immediately after a curettage for those patients who have no signs or symptoms of infection, this is not always possible. In most institutions operating rooms are available 24 hours a day for emergency Int J Gynaecol Obstet 15
surgery, but elective surgery must usually be scheduled in advance. Therefore, laparoscopy cannot usually be performed concurrently with an emergency curettage. Since elective laparoscopy can be scheduled for the day the patient is to be discharged from the hospital, delaying the procedure does not increase the total time the patient is hospitalized. It is still too early to adequately evaluate the failure rate associated with the application of tubal rings after a patient is treated for an inevitable or incomplete abortion. The failure rate for our study at this time (none of the 85 women followed up for 6 or more months have become pregnant) is comparable to the rate (about 1%) reported for interval tubal ring laparoscopics (1, 6, 8). Until a few years ago, insertion of an IUD was not recommended after treatment of a septic abortion. Several studies (4, 5, 11), however, have since documented that IUDs can be inserted after a septic abortion without increasing the risk of complications. Similarly, objections may be raised to performing a sterilization after treatment of a septic abortion. However, the results of the present study do not indicate a higher risk of complications for the patient when the sterilization is performed after treatment of a septic or aseptic incomplete abortion. ACKNOWLEDGMENT This study was supported in part by the International Fertility Research Program, Research Triangle Park, North Carolina, USA (AID/csd2979).
REFERENCES 1. Brenner, W E, Edelman, D A, Black, T & Goldsmith, A: Complications of laparoscopic sterilization with electrocautery, spring-loaded clips, and silastic bands. Fértil Steril 27:256, 1976. 2. Courey, N G & Cunanan, R G: Combined laparoscopic sterilization and pregnancy termination. J Reprod Med 10:291, 1973. 3. Fishburne, J I, Edelman, D A, Hulka, J F & Mercer, J P: Combined outpatient laparoscopic sterilization and therapeutic abortion by vacuum aspiration. Obstet Gynecol 45:665, 1975. 4. Goldsmith, A, Edelman, D A & Brenner, W E: Contraception immediately postabortion. Adv Plann Parent 70:38, 1975. 5. Goldsmith, A, Goldberg, R, Eyzaguirre, H & Lizana, L: Immediate postabortal intrauterine contraceptive device insertion: a double-blind study. Am J Obstet Gynecol 772:957, 1972. 6. King, T M & Yoon, I B: The Falope ring sterilization procedure. Paper presented to the Conception Control Subcommittee of the Panel on Review of Obstetrical-Gynecologic Devices, June 21-22, 1976.
Postabortion laparoscopic sterilization
Kumarasamy, T, Hulka, J F, Mercer, J P, Fishburne, J I & Omran, K F: Spring clip tubal occlusions: a report of the first 400 cases. Fértil Steril 26.1116, 1976. Kwak, H M, Saha, A & Pachauri, S: Tubal ring technique of laparoscopic sterilization. Paper presented at the Second International Congress of Gynecologic Endoscopy, Las Vegas, Nevada, November 20-23, 1975. Phillips, J, Keith, D, Hulka, J, Hulka, B & Keith, L: Gynecologic laparoscopy in 1975. J Reprod Med Í6.-105, 1976. 10. Quan, A & de Badia, D: Sterilization at the Maternity Hospital of El Salvador. Paper presented at the Third International Conference on Voluntary Sterilization, Tunis, Tunisia, February 1-4, 1976. 11. Quan, A, Edelman, D A, Goldsmith, A, Thomas, M & Zappala-Badia, D: Immediate post-abortion insertion of the Dalkon Shield. Contraception 12:23, 1975.
261
12. Shepard, M K: Female contraceptive sterilization. Obstet Gynecol Surv 29:739, 1974. 13. Wheeless, C R & Thompson, B H: Laparoscopic sterilization: review of 3 600 cases. Obstet Gynecol 42:751, 1973.
Address for reprints: International Fertility Research Program Research Triangle Park North Carolina 27709 USA
Int J Gynaecol Obstet 15
Laparoscopic Sterilization After 4 ' Spontaneous" Abortion Angel Quan1, Delfina de Badia 1 , David A. Edelman2, and Alfredo Goldsmith2 1
University of El Salvador School of Medicine, San Salvador, El Salvador International Fertility Research Program, Research Triangle Park, North Carolina, USA
2
ABSTRACT Quan, A., de Badia, D., Edelman, D. A. and Goldsmith, A. (University of El Salvador School of Medicine, San Salvador, El Salvador, and the International Fertility Research Program, Research Triangle Park, North Carolina, USA). Laparoscopic sterilization after "spontaneous" abortion. Int J Gynaecol Obstet 15: 258-261, 1977 One hundred eighty-nine patients were evaluated to assess the safety of laparoscopic sterilization after completion of a "spontaneous" abortion by curettage. Some of the "spontaneous" abortions had probably been illegally initiated outside the hospital and were septic. The laparoscopic sterilization procedures used tubal rings to achieve tubal occlusion. They were performed 4 to 48 hours after completion of the abortion. Patients were discharged from the hospital on the day the procedure was performed. Surgical difficulties and complications associated with the laparoscopy were infrequent. Undergoing a curettage prior to sterilization with tubal rings by laparoscopy did not appear to result in increased rates of complications.
INTRODUCTION The lowering of the age/parity requirements for sterilization and the introduction of laparoscopic methods at the Maternity Hospital of El Salvador in 1972 have resulted in a continual increase in the demand for sterilization services. From 1956 to 1965, 2 879 sterilization procedures were performed; in contrast, from 1973 to 1975 more than 12 000 procedures were performed (10). In the past year, about 72.0% of the sterilizations were performed after vaginal term deliveries; 9.0% were performed after a cesarean section; 17.0% were interval procedures; and 1.3% were performed after completion of inevitable or incomplete abortions. Various reports document the safety of interval laparoscopic sterilization (9,12,13), and others have shown that the rates of complications or surgical difficulties associated with laparoscopic sterilization after induced abortion are not significantly higher than for interval procedures (2, 3). However, no studies have reported on the safety of sterilization after inevitable or incomplete abortions, particularly after septic abortions. This study was undertaken to evaluate the safety of performing laparoscopic sterilization either immediately or soon Int J Gynaecol Obstet 15
after curettage for inevitable or incomplete abortions, including some septic abortions. METHODS AND MATERIALS From May 1975 to May 1976, 189 women, admitted to the Maternity Hospital of El Salvador for treatment of an inevitable or incomplete abortion, underwent a curettage followed by laparoscopic sterilization with tubal rings for tubal occlusion before they were discharged from the hospital Abortion procedures Unless a prolonged hospitalization was necessary for the treatment of abortion-related complications, women were usually discharged from the hospital on the same day or on the first postoperative day. Most abortions were probably not spontaneous but were illegally initiated outside of the hospital by inserting a rubber catheter into the uterus. On admission, 10.1% of the patients were classified as having a septic abortion. They usually had a fever of over 38°C, and the attending physician judged the sepsis to be confined to the uterus. Patients with a septic abortion were treated with antibiotics before undergoing dilatation and curettage (D&C). Sterilization procedures Sterilization was performed 4 to 48 hours after curettage depending on the time of day the abortion was treated, on the availability of the operating room, and on the status of the patient. No patient was scheduled for laparoscopy until she was afebrile. All procedures were single p u n c t u r e laparoscopics, performed under neuroleptanalgesia and local anesthesia. Half an hour before surgery, the patient was requested to urinate and 0.5 mg of atropine was administered intramuscularly. Prior to surgery 1 cc Thalamonal (Janssen Pharmaceutica brand of fentanyl citrate 0.05 mg and droperidol 2.5 mg per cc), followed by 50 mg meperidine and 5 mg diazepam, were administered intravenously in the operating room. The patient's abdomen was washed
Postabortion
with Betadine (Purdue Frederick Co. brand of povidone-iodine) and 20 cc 2% lidocaine was injected immediately below and around the umbilicus. Pneumoperitoneum was achieved with about 2 liters of C0 2 . Tubal occlusion was effected by applying tubal rings with a specially designed laparoscope (Fig. 1). This laparoscope consists of a standard laparoscopic lens system, a fiber-optic light source, and a ring applicator system consisting of two cylinders and a retractable grasping forceps within the inner cylinder (Fig. 2). The tubal ring (2.5 mm thick, with a 1 mm inner diameter and a 4 mm outer diameter) is fitted over the outer surface of the inner cylinder. After the Fallopian tube is identified, it is grasped at its isthmic portion with the forceps and retracted into the inner cylinder of the laparoscope. By sliding the inner cylinder within the outer cylinder of the applicator, the tubal ring is pushed off the inner cylinder and over the loop of Fallopian tube contained within the inner cylinder. The grasping forceps is then moved forward to release the loop of occluded tube. The same procedure is performed on the opposite tube. After the procedure was completed, the patients were discharged to the recovery area and observed for 2 hours before they were discharged from the hospital. Each patient was instructed to return to the hospital for a history and a physical examination at 3 weeks and at 6 and 12 months after sterilization. Subjects All but one patient reported at least one prior abortion. The median age and median parity of the patients were 31.4 years and 4.6 live births. Most patients (56.6%) were 30 to 39 years of age and were grand multiparas (50.5%) (Table I). All women had at least one living child. Three to 12 weeks after the sterilization, 84.7% returned for the scheduled follow-up visit. To date, 45.0% have been followed up for more than 6 months.
laparoscopic
sterilization
259
Fig. 2. Close-up view of the distal end of the tubal ring applicator showing the grasping forceps in the extended position and the tubal ring fitted over the inner cylinder.
RESULTS Surgical difficulties occurred during six (3.2%) of the sterilization procedures. The surgeon had difficulty visualizing the tubes as a result of an enlarged uterus in four cases. The tubes could not be mobilized easily because of adhesions between the tubes and other pelvic structures in two patients. Complications were infrequent and occurred for six patients (3.2%): tears of the tube in four cases; emphysema of the abdominal wall in one case; tuboovarian abscess in one case. For the four patients in whom the tube was inadvertently transected by Table I. Age and parity distributions
No. Age (years) 20-29 30-39 40 or more AAedian
69 107 13
Parity 1-2 3-4 5-6 7 or more AAedian
18 75 38 57
36.5 56.6 6.9 31.4 9.6 39.9 20.2 30.3 4.6
Fig. 1. Single-incision laparoscope used to apply tubal rings (manufactured by KLI, Inc., Ivyland, Penn., USA).
Int J Gynaecol Obstet 15
260 A. Quan et al
tearing the tube, the tube was occluded by applying a tubal ring to each end of the transected tube. In one patient, a 38-year-old para 6-0-1-6, laparoscopy revealed an edematous left tube. The right tube was even more edematous and was immobile because of adhesions. A tubal ring was applied to the left tube, but electrocoagulation was elected for the right tube. The patient was readmitted to the hospital 2 weeks later with fever. She developed a tubo-ovarian abscess and underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy 23 days after the sterilization. This patient was probably admitted to the hospital with occult sepsis in which the infection had already spread to the right tube and ovary. However, the diagnosis of a septic abortion was not made at the time she was admitted to the hospital. All patients were discharged from the hospital on the day the sterilization procedure was performed, except for two who were hospitalized overnight for their convenience. Only the one patient with a tuboovarian abscess was rehospitalized for treatment of a complication. To date, no pregnancies have been reported, and 85 patients have been followed up for 6 or more months.
COMMENT Laparoscopic sterilization with tubal rings, performed immediately after treatment of an inevitable or incomplete abortion, apparently poses no higher risk of complications or surgical difficulties than interval laparoscopy. The overall complication rate (3.2%) in this study is similar to that reported by other investigators using tubal rings, electrocoagulation, or spring-loaded clips for tubal occlusion at laparoscopy (1, 7, 8). In this study the most frequent complications, transection/tears of the Fallopian tubes, occurred in four cases (2.1%), usually when the Fallopian tube was retracted into the inner cylinder of the laparoscope. The rate is similar to the rate reported by other investigators (6). Difficulty in retracting the tube may be more likely for patients with edematous tubes because the inside diameter of the inner cylinder is only 4.7 mm. This difficulty, which may be more frequent among postabortion patients, only occasionally results in tears of the Fallopian tubes. Although the staff and facilities may be used more efficiently when laparoscopy is performed immediately after a curettage for those patients who have no signs or symptoms of infection, this is not always possible. In most institutions operating rooms are available 24 hours a day for emergency Int J Gynaecol Obstet 15
surgery, but elective surgery must usually be scheduled in advance. Therefore, laparoscopy cannot usually be performed concurrently with an emergency curettage. Since elective laparoscopy can be scheduled for the day the patient is to be discharged from the hospital, delaying the procedure does not increase the total time the patient is hospitalized. It is still too early to adequately evaluate the failure rate associated with the application of tubal rings after a patient is treated for an inevitable or incomplete abortion. The failure rate for our study at this time (none of the 85 women followed up for 6 or more months have become pregnant) is comparable to the rate (about 1%) reported for interval tubal ring laparoscopics (1, 6, 8). Until a few years ago, insertion of an IUD was not recommended after treatment of a septic abortion. Several studies (4, 5, 11), however, have since documented that IUDs can be inserted after a septic abortion without increasing the risk of complications. Similarly, objections may be raised to performing a sterilization after treatment of a septic abortion. However, the results of the present study do not indicate a higher risk of complications for the patient when the sterilization is performed after treatment of a septic or aseptic incomplete abortion. ACKNOWLEDGMENT This study was supported in part by the International Fertility Research Program, Research Triangle Park, North Carolina, USA (AID/csd2979).
REFERENCES 1. Brenner, W E, Edelman, D A, Black, T & Goldsmith, A: Complications of laparoscopic sterilization with electrocautery, spring-loaded clips, and silastic bands. Fértil Steril 27:256, 1976. 2. Courey, N G & Cunanan, R G: Combined laparoscopic sterilization and pregnancy termination. J Reprod Med 10:291, 1973. 3. Fishburne, J I, Edelman, D A, Hulka, J F & Mercer, J P: Combined outpatient laparoscopic sterilization and therapeutic abortion by vacuum aspiration. Obstet Gynecol 45:665, 1975. 4. Goldsmith, A, Edelman, D A & Brenner, W E: Contraception immediately postabortion. Adv Plann Parent 70:38, 1975. 5. Goldsmith, A, Goldberg, R, Eyzaguirre, H & Lizana, L: Immediate postabortal intrauterine contraceptive device insertion: a double-blind study. Am J Obstet Gynecol 772:957, 1972. 6. King, T M & Yoon, I B: The Falope ring sterilization procedure. Paper presented to the Conception Control Subcommittee of the Panel on Review of Obstetrical-Gynecologic Devices, June 21-22, 1976.
Postabortion laparoscopic sterilization
Kumarasamy, T, Hulka, J F, Mercer, J P, Fishburne, J I & Omran, K F: Spring clip tubal occlusions: a report of the first 400 cases. Fértil Steril 26.1116, 1976. Kwak, H M, Saha, A & Pachauri, S: Tubal ring technique of laparoscopic sterilization. Paper presented at the Second International Congress of Gynecologic Endoscopy, Las Vegas, Nevada, November 20-23, 1975. Phillips, J, Keith, D, Hulka, J, Hulka, B & Keith, L: Gynecologic laparoscopy in 1975. J Reprod Med Í6.-105, 1976. 10. Quan, A & de Badia, D: Sterilization at the Maternity Hospital of El Salvador. Paper presented at the Third International Conference on Voluntary Sterilization, Tunis, Tunisia, February 1-4, 1976. 11. Quan, A, Edelman, D A, Goldsmith, A, Thomas, M & Zappala-Badia, D: Immediate post-abortion insertion of the Dalkon Shield. Contraception 12:23, 1975.
261
12. Shepard, M K: Female contraceptive sterilization. Obstet Gynecol Surv 29:739, 1974. 13. Wheeless, C R & Thompson, B H: Laparoscopic sterilization: review of 3 600 cases. Obstet Gynecol 42:751, 1973.
Address for reprints: International Fertility Research Program Research Triangle Park North Carolina 27709 USA
Int J Gynaecol Obstet 15
