Acta Obstet Gynecol Scand 58: 169-173, 1979
MENSTRUAL REGULATION AS A METHOD FOR EARLY TERMINATION O F PREGNANCY Matti Mandelin and Olavi Karjalainen From Departments I and I1 of Obstetrics and Gynecology, University Central Hospital, Helsinki, Finland
Abstract. 116 women with documented or suspected pregnancy underwent an endometrial aspiration for early termination. Their menses delay was between 7 and 22 days. A standard 3 mm Vabraa aspirator was used. 90.5% were actually pregnant. The success rate was 97.1 %. The total complication rate was 6.8%, the most common complication being endometritis. Three patients required a re-evacuation because of prolonged bleeding. In this series there were two ectopic pregnancies and nine cases of ovum abortivum, of which one later turned out to be a hydatiform mole. The procedure was well tolerated by the patients. No sick-leave was given. The postoperative bleeding averaged 10 days in primigravid and 7 days in parous patients.
Efforts to avoid the risks associated with legal abortion performed during the second or late first trimester of pregnancy have lead to the application of new techniques such as vaginal administration of prostaglandin derivatives (4) and the use of minisuction curettage in the termination of early pregnancy. The latter method, also called “menstrual regulation’’, was first reported by Karman and Potts in 1972 (7). It has since been widely tested in various countries (1, 3, 10, 14, 16) and is now common practice in many centres, e.g. in the U.S. (8). Menstrual regulation (MR) is performed in most centres up to 14 days after the expected date of menstruation. In most studies it has proved to be a safe and effective method for early pregnancy termination (1, 3, 14, 16), but some investigators have reported failure rates exceeding 10% in proven cases of pregnancy (1). The rate of unnecessary aspirations done to nonpregnant women is reported to vary between 5 and 30%, depending on the length of the menses delay (1, 10). Unnecessary measures are obviously done even in cases of proven pregnancy because an appreciable number of defective ova would be expelled spontaneously during the next weeks of pregnancy (9). As regards the arrangement of postabortal fertility control, one has to consider that the first menstrual cycle after a conventional
abortion may be ovulatory in only 10 per cent ( 1 I), although rates as high as 85% have been reported (2). Knowledge of restoration of ovulatory function after menstrual regulation seems to be lacking. The present study was designed both to evaluate the effectiveness of endometrial aspiration as a means of early abortion and to chart the reestablishment of ovulation after this procedure. PATIENTS AND METHODS The series consisted of 116 normally menstruating women whose menstrual delay was between 7 and 22 days. The measures were performed as an out-patient procedure by the same physician. Before the curettage the patients were informed about the nature of the procedure and given contraceptive advice. In cases of frank cervicitis, the procedure was postponed a few days while antibacterial treatment was given. A great majority of the patients had already been tested for pregnancy by remitting doctors. If the test was negative or no previous tests existed, a pregnancy tube test (Pregnosticon All-In@, Organon Company, Oss, Holland) was performed. Other laboratory evaluation consisted of a Papanicolau smear, and cultures for trichomonas, candida, and gonococci for each patient. The curettage was performed by using standard Vabraa curettes with a 3 mu wide metal cannula and a plastic compartment for tissue collection (Ferrosan A& Copenhagen, Denmark). A conventional electric vacuum pump was used a a vacuum source. No preoperative medication was employed. Parous patients received no local anaesthesia, while for most (80%) of the nulliparae a paracervical block was administered. The vacuum pressure used in the procedure was 0.5 kp/cmz. No cervical dilatation was employed. All the suction material was sent to a histopathological examination done by the same pathologist. The histologic criteria for pregnancy included decidua with villi, the occurrence of throphoblasts even without villi, or gestational hyperplasia of the endometrium. If the patient desired, an IUD (Copper-T-200, Leiras, Turku, Finland) was inserted at the end of the procedure. The time required for the curettage averaged 5 min. After the procedure, the patients were allowed to leave the hospital immediately and resume their usual activities. No sick-leave was given, and the patients commenced Acta Obstet Gynecol Scand 58 f 197%
170
M . Mandelin and 0 .Karjalainen
Table I. Age and parity distribution of the patients Age -18 19-25 26-30 3 1-35 36Total
Primigravidae
Parous
Total 1
1.0
I
6 22 22
28.0 32.0 25.0
2 52
14 64
33 37 29 16 116
1
21 15
%
suggests an inadequate tissue yield in preparing the histological specimen. There were no false positive pregnancy tests, while 12 patients, including the two cases of extrauterine pregnancy, had a false negative pregnancy test. The culture for gonococci was positive in three cases.
14.0 100.0
Acceptability of the procedure The patients’ estimates of pain involved in the procedure are shown in Table IV. Practically all primigravidae felt some pain, in spite of the local their work on the same or the following day. An information leaflet about possible complications was given to the anaesthesia, whereas almost one fifth of the parous patients and they were instructed to measure their basal patients felt no pain although no anaesthesia was body temperature and observe their bleeding until the first used. postoperative check-up 3 weeks later. A weekly blood Six patients felt dizzy after the procedure, requirsample for plasma progesterone determination was taken ing observation at the polyclinic for about half an from 29 patients. Plasma progesterone determinations were carried out using a radioimmune assay method based hour. There was no clear correlation between the on the Devilla-Janne method, without, however, column pain felt and the symptoms. separation (5, 6). A plasma progesterone level above 5 nghl(15.9 nmoU1) was accepted as the criterion for ovulation (12).
RESULTS Patient characteristics The age of the patients ranged between 17 and 45 years, with approximately two thirds between 19 and 30 years (see Table I). The proportions of primigravidae and parous women were almost equal. The length of amenorrhoea and menses delay are illustrated in Table 11. About 72% of the patients had an amenorrhoea of between 36 and 45 days, the menses delay being between 1 1 and 20 days in 84% of the cases. There were very few women with less than 36 or more than 50 days of amenorrhoea. Laboratory examinations The histopathological findings are given in Table 111. In the 103 intrauterine pregnancies the product of conception was normal in 87 patients (85%), while in 9 cases (9%) the histopathological diagnosis was a typical ovum abortivum. One of these was later found to be a hydatiform mole. In both tubal pregnancies the endometrium showed a decidual reaction. There were 7 additional cases with the same histological finding. Three of these cases were failures, while 4 had a normal, uneventful postoperative course. The finding in these cases Acta Obstet Gynecol Scand 58 (1979)
Complications There were no surgical complications. Three patients were re-evacuated because of cramps and heavier postoperative bleeding. In all these cases the reason was found to be retained tissue. One patient required a blood transfusion. There were 3 failures in the series (2.9%). The histopathological diagnosis in all these patients was reactio decidualis. In one case the procedure was repeated, the other two underwent a standard suction evacuation. There were no severe postoperative infections in the series. Four patients, including one with a positive gonococcal culture, were treated because of endometritis. All infections occurred in patients who received an IUD. All complications occurred in patients with a proven pregnancy. The duration of postoperative bleeding averaged
Table 11. Length of amenorrhoea and menses delay Length of amenorrhoea
Menses delay
Days
No.
%
Days
No.
-35 36-40 4145 6 5 0 5 1Total
4 22 61 26 3 116
3.5 19.0 52.5 22.5 2.5 100.0
-10 11-15 16-20 21-
15 61 36 4
13.0 52.5 31.0 3.5
Total
116
100.0
%
Menstrual regulation
Table 111. Histology of aspirated material andfinal diagnosis
Table IV. Subjective pain rarings immediately afier the procedure
Diagnosis
Histology
Intrauterine pregnancy
Normal 87 pregnancy Ovum abortivum 8 Hydatiform mole 1 DeciduaJ reaction 7 Secretory 0 endometrium Proliferative 0 endometrium Total 103
Tuba1 pregnancy
Not pregnant
No pain Slight Moderate Severe Total
Total
0
0
87
0
0
8
0
0
1
2
0
9
0
4
4
0
7
7
2
11
116
8 days (range CL21 days). About 20% of the patients
without an IUD felt contractions during the postoperative period for some days. The two cases of tuba1 pregnancy reported discomfort from the first postoperative day on and were operated after the onset of more severe symptoms.
171
Primigravidae
Parous
1 20 31 0
11 26 26 1
52
64
Total 12
46 57 1 116
The patient with molar pregnancy had an uneventful postoperative course until 2 months later, when she returned to the polyclinic complaining of irregular bleeding and general symptoms of pregnancy. Examination then revealed uterine enlargement corresponding to a 16 to 18 weeks pregnancy. Ultrasound examination was typical of hydatiform mole. The patient underwent a prostaglandin induction and suction curettage. Restoration of ovulation Plasma progesterone samples were obtained from 29 patients, of whom 24 had been pregnant at the time of the procedure. Their plasma progesterone levels are illustrated in Fig. 1. By the 21st postoperative day, only 3 patients had values above 16 nmol/l (5 nglml), suggesting ovulation. Four additional patients showed somewhat less elevated values. Of all pregnant patients, 17 % had a rise in BBT suggesting possible ovulation by the 21st postoperative day. This observation fits with the onset of their first menstruation after the menstrual regulation procedure. Approximately 60% of all pregnant patients had their first menstruation before the 40th postoperative day. The mean procedure-menstruation interval was 37 days, range 21-65 days.
DISCUSSION
1
0
1
14
21
DAYS
Fig. 1. Plasma progesterone concentrations after the procedure (logarithmic scale).
In this study on 116 women with documented or suspected pregnancy evacuated with a standard Vabra aspirator, the success rate was 97%, while the total complication rate was 6.8%. Similar studies from other centres show a total complication rate of between 0.2 and 11.0% (14), being in general of the same order as in standard vacuum extraction techniques used in later first trimester abortion (13, 15). Acta Obsrrt Gynccol Scand 58 (1979)
172
M . Mandelin and 0 .Karjalainen
Some 10% of the women applying for MR procedure were not pregnant, thus representing the group undergoing an unnecessary operation. This percentage is lower than generally reported (lo), possibly due to the fact that the majority (70%) of the patients were more than 13 days overdue. It is possible that referring doctors were more liable to send patients with positive pregnancy tests. The use of more sensitive tests will naturally minimize the possibility of unnecessary procedures. A disadvantage of this method is that the detection of extrauterine pregnancies is rather difficult. The histopathologic diagnosis of decidual reaction may as well be due to a failure in the evacuation procedure as to extrauterine pregnancy or, as shown in this series, to a failure in tissue processing for histology. Therefore, a histological diagnosis of decidual reaction calls for very close follow-up. In our opinion, menstrual regulation always demands a histopathological examination of the aspirated tissue. A thorough follow-up is necessary also in order to reveal possible failures, another problem hardly encountered with conventional abortion technique. To reduce failure incidence, it may be advisable to wait until the patients are at least 14 days overdue, as all the failures in this series occurred in patients whose menses delay was shorter than that. Most MR studies have been done using soft Karman plastic cannulas. In this study a standard 3 mm Vabra aspirator was used but the rigid and relatively narrow cannula presented no problems. There were no perforations, and in the few cases where the cannula was blocked by tissue, the blockage was easily overcome by increasing the vacuum. The Vabra aspirator, which has a chamber for tissue collection, was found well suited for the purpose. Soft plastic cannulas, of course, reduce the risk of perforation. Boyd & Holmstrom (2) found in their series of conventional abortion that, on the basis of endometrial biopsy, about 50% of the patients had ovulated by the 22nd postoperative day. Although in this study the corresponding figure was only some 13%, some immediate postabortal contraception is nevertheless called for. In this series, there were 8 proven cases of ovum abortivum and 1 case of hydatiform mole, representing an 8.7% incidence of defective ova of the intrauterine pregnancies. This incidence was clearly lower than we expected on the basis of reActa Obstet Gynecol Scand 58 (1979)
ports by investigators involved in human fertility studies (9). Thus, the importance of pathologic ova as a cause of unnecessary artificial termination may not be of great significance. CONCLUSION The menstrual regulation type of pregnancy termination has some clear advantages compared with the standard VE procedure later in the first trimester. As a simple, rapid measure done in the earliest weeks of pregnancy, it reduces the emotional stress that is associated with the termination of an unwanted pregnancy in a later stage. It allows the patients to resume their normal activities immediately. Its complication rates are within reasonable limits and, combined with efficient follow-ups, it contributes very favourably to the management of unwanted pregnancies. REFERENCES 1. Atienza, M. F., Burkman, R. T., King, T. M., Burnett, L. S., Lau, H. L., Parmley, T. M. &
Woodruff, J. D.: Menstrual extraction. Am J Obstet Gynecoll21: 490, 1975. 2. Boyd, E. F. & Holmstrom, E. G.: Ovulation following therapeutic abortion. Am J Obstet Gynecol 113: 469, 1972. 3. Brenner, W. E., Edelman, D. A. & Kessel E.: Menstrual regulation in the United States: A preliminary report. Fertil Steril26: 289, 1975. 4. Bygdeman, M., BoreU, U., Leader, A., Lundstriim, V., Martin, J. N . & Eneroth, P.: Induction of first and second trimester abortion by the vaginal administration of 15-methyCPGF,-methyl ester. I n Advances in Prostaglandin and Thromboxane Research (eds. B. Samuelson & R. Paoletti), vol. 2, p. 693. Raven Press, New York, 1976. 5 . Devilla, G. O., Jr., Roberts, K., Wiest, W.G., Mikhail, G. & Flickinger, G.: A specific radioimmunoassay of plasma progesterone. J Clin Endocrinol Metab 35: 458, 1972. 6. Janne, O., Apter, D. & Vihko, R.: Assay of testosterone, progesterone and 17a-hydroxyprogesterone in human plasma by radioimmunoassay on hydroxyalkoxypropyl Sephadex. J Steroid Biochem 5: 155, 1974. 7. Karman, H. & Potts, M.: Very early abortion using syringe as vacuum source. Lancet 1: 1051, 1972. 8. Lancet, Editorial, p. 947, May 1976. 9. Leridon, H.: Dkmographie des Cchecs de la reproduction. I n Les Accidents Chromosomiques de la Reproduction (eds. A. BouC & C. Thibault), p. 13. INSERM, Paris, 1973. 10. Miller, E. R., Fortney, J. A. & Kessel, E.: Early vacuum aspiration: Minimizing procedures to nonpregnant women. Fam Plan Perspect 8: 33, 1976.
Menstrual regulation 11. Purola, E. & Nerdrum, T.: Re-establishment of menstruation after abortion. Ann Chir Gynaecol Fenn 57:618, 1968. 12. Ross, G. T., Cargille, C. M., Lipsett, M. B., Rayfard, P. L., Marshall, J. R., Strott, C. A. & Rodbard, D.: Pituitary and gonadal hormones in women during spontaneous and induced ovulatory cycles. Rec Prog Horm Res 26: 1, 1970. 13. Sigurdsson, K.: Aborter vid Nacka sjukhus 1975-somatiska komplikationer och preventivteknik. Sv. Lakartidningen 74: 318, 1977. 14. Stringer, J., Anderson, M., Beard, R. W.,Fairweather, D. V. I. & Steele, s. J.: Very early termination of pregnancy (menstrual extraction). Br Med J 3:7, 1975.
173
15. Tietze, C. & Murstein, M. C.: Abortion Factbook
1975, Reports on PopulationtFamity Planning No. 14, 2nd ed., December. 16. Van der Vlugt, T. & Piotrow, P. T.: Menstrual regulation update. Population Report, Series F, No.4, May 1974. Submitted for publication Jan. 17, 1978
Matti Mandelin Department of Obstetrics and Gynecology I and I1 University Central Hospital Helsinki Finland
Actn Obstet Gynecol Sccind 58 (1979)
MENSTRUAL REGULATION AS A METHOD FOR EARLY TERMINATION O F PREGNANCY Matti Mandelin and Olavi Karjalainen From Departments I and I1 of Obstetrics and Gynecology, University Central Hospital, Helsinki, Finland
Abstract. 116 women with documented or suspected pregnancy underwent an endometrial aspiration for early termination. Their menses delay was between 7 and 22 days. A standard 3 mm Vabraa aspirator was used. 90.5% were actually pregnant. The success rate was 97.1 %. The total complication rate was 6.8%, the most common complication being endometritis. Three patients required a re-evacuation because of prolonged bleeding. In this series there were two ectopic pregnancies and nine cases of ovum abortivum, of which one later turned out to be a hydatiform mole. The procedure was well tolerated by the patients. No sick-leave was given. The postoperative bleeding averaged 10 days in primigravid and 7 days in parous patients.
Efforts to avoid the risks associated with legal abortion performed during the second or late first trimester of pregnancy have lead to the application of new techniques such as vaginal administration of prostaglandin derivatives (4) and the use of minisuction curettage in the termination of early pregnancy. The latter method, also called “menstrual regulation’’, was first reported by Karman and Potts in 1972 (7). It has since been widely tested in various countries (1, 3, 10, 14, 16) and is now common practice in many centres, e.g. in the U.S. (8). Menstrual regulation (MR) is performed in most centres up to 14 days after the expected date of menstruation. In most studies it has proved to be a safe and effective method for early pregnancy termination (1, 3, 14, 16), but some investigators have reported failure rates exceeding 10% in proven cases of pregnancy (1). The rate of unnecessary aspirations done to nonpregnant women is reported to vary between 5 and 30%, depending on the length of the menses delay (1, 10). Unnecessary measures are obviously done even in cases of proven pregnancy because an appreciable number of defective ova would be expelled spontaneously during the next weeks of pregnancy (9). As regards the arrangement of postabortal fertility control, one has to consider that the first menstrual cycle after a conventional
abortion may be ovulatory in only 10 per cent ( 1 I), although rates as high as 85% have been reported (2). Knowledge of restoration of ovulatory function after menstrual regulation seems to be lacking. The present study was designed both to evaluate the effectiveness of endometrial aspiration as a means of early abortion and to chart the reestablishment of ovulation after this procedure. PATIENTS AND METHODS The series consisted of 116 normally menstruating women whose menstrual delay was between 7 and 22 days. The measures were performed as an out-patient procedure by the same physician. Before the curettage the patients were informed about the nature of the procedure and given contraceptive advice. In cases of frank cervicitis, the procedure was postponed a few days while antibacterial treatment was given. A great majority of the patients had already been tested for pregnancy by remitting doctors. If the test was negative or no previous tests existed, a pregnancy tube test (Pregnosticon All-In@, Organon Company, Oss, Holland) was performed. Other laboratory evaluation consisted of a Papanicolau smear, and cultures for trichomonas, candida, and gonococci for each patient. The curettage was performed by using standard Vabraa curettes with a 3 mu wide metal cannula and a plastic compartment for tissue collection (Ferrosan A& Copenhagen, Denmark). A conventional electric vacuum pump was used a a vacuum source. No preoperative medication was employed. Parous patients received no local anaesthesia, while for most (80%) of the nulliparae a paracervical block was administered. The vacuum pressure used in the procedure was 0.5 kp/cmz. No cervical dilatation was employed. All the suction material was sent to a histopathological examination done by the same pathologist. The histologic criteria for pregnancy included decidua with villi, the occurrence of throphoblasts even without villi, or gestational hyperplasia of the endometrium. If the patient desired, an IUD (Copper-T-200, Leiras, Turku, Finland) was inserted at the end of the procedure. The time required for the curettage averaged 5 min. After the procedure, the patients were allowed to leave the hospital immediately and resume their usual activities. No sick-leave was given, and the patients commenced Acta Obstet Gynecol Scand 58 f 197%
170
M . Mandelin and 0 .Karjalainen
Table I. Age and parity distribution of the patients Age -18 19-25 26-30 3 1-35 36Total
Primigravidae
Parous
Total 1
1.0
I
6 22 22
28.0 32.0 25.0
2 52
14 64
33 37 29 16 116
1
21 15
%
suggests an inadequate tissue yield in preparing the histological specimen. There were no false positive pregnancy tests, while 12 patients, including the two cases of extrauterine pregnancy, had a false negative pregnancy test. The culture for gonococci was positive in three cases.
14.0 100.0
Acceptability of the procedure The patients’ estimates of pain involved in the procedure are shown in Table IV. Practically all primigravidae felt some pain, in spite of the local their work on the same or the following day. An information leaflet about possible complications was given to the anaesthesia, whereas almost one fifth of the parous patients and they were instructed to measure their basal patients felt no pain although no anaesthesia was body temperature and observe their bleeding until the first used. postoperative check-up 3 weeks later. A weekly blood Six patients felt dizzy after the procedure, requirsample for plasma progesterone determination was taken ing observation at the polyclinic for about half an from 29 patients. Plasma progesterone determinations were carried out using a radioimmune assay method based hour. There was no clear correlation between the on the Devilla-Janne method, without, however, column pain felt and the symptoms. separation (5, 6). A plasma progesterone level above 5 nghl(15.9 nmoU1) was accepted as the criterion for ovulation (12).
RESULTS Patient characteristics The age of the patients ranged between 17 and 45 years, with approximately two thirds between 19 and 30 years (see Table I). The proportions of primigravidae and parous women were almost equal. The length of amenorrhoea and menses delay are illustrated in Table 11. About 72% of the patients had an amenorrhoea of between 36 and 45 days, the menses delay being between 1 1 and 20 days in 84% of the cases. There were very few women with less than 36 or more than 50 days of amenorrhoea. Laboratory examinations The histopathological findings are given in Table 111. In the 103 intrauterine pregnancies the product of conception was normal in 87 patients (85%), while in 9 cases (9%) the histopathological diagnosis was a typical ovum abortivum. One of these was later found to be a hydatiform mole. In both tubal pregnancies the endometrium showed a decidual reaction. There were 7 additional cases with the same histological finding. Three of these cases were failures, while 4 had a normal, uneventful postoperative course. The finding in these cases Acta Obstet Gynecol Scand 58 (1979)
Complications There were no surgical complications. Three patients were re-evacuated because of cramps and heavier postoperative bleeding. In all these cases the reason was found to be retained tissue. One patient required a blood transfusion. There were 3 failures in the series (2.9%). The histopathological diagnosis in all these patients was reactio decidualis. In one case the procedure was repeated, the other two underwent a standard suction evacuation. There were no severe postoperative infections in the series. Four patients, including one with a positive gonococcal culture, were treated because of endometritis. All infections occurred in patients who received an IUD. All complications occurred in patients with a proven pregnancy. The duration of postoperative bleeding averaged
Table 11. Length of amenorrhoea and menses delay Length of amenorrhoea
Menses delay
Days
No.
%
Days
No.
-35 36-40 4145 6 5 0 5 1Total
4 22 61 26 3 116
3.5 19.0 52.5 22.5 2.5 100.0
-10 11-15 16-20 21-
15 61 36 4
13.0 52.5 31.0 3.5
Total
116
100.0
%
Menstrual regulation
Table 111. Histology of aspirated material andfinal diagnosis
Table IV. Subjective pain rarings immediately afier the procedure
Diagnosis
Histology
Intrauterine pregnancy
Normal 87 pregnancy Ovum abortivum 8 Hydatiform mole 1 DeciduaJ reaction 7 Secretory 0 endometrium Proliferative 0 endometrium Total 103
Tuba1 pregnancy
Not pregnant
No pain Slight Moderate Severe Total
Total
0
0
87
0
0
8
0
0
1
2
0
9
0
4
4
0
7
7
2
11
116
8 days (range CL21 days). About 20% of the patients
without an IUD felt contractions during the postoperative period for some days. The two cases of tuba1 pregnancy reported discomfort from the first postoperative day on and were operated after the onset of more severe symptoms.
171
Primigravidae
Parous
1 20 31 0
11 26 26 1
52
64
Total 12
46 57 1 116
The patient with molar pregnancy had an uneventful postoperative course until 2 months later, when she returned to the polyclinic complaining of irregular bleeding and general symptoms of pregnancy. Examination then revealed uterine enlargement corresponding to a 16 to 18 weeks pregnancy. Ultrasound examination was typical of hydatiform mole. The patient underwent a prostaglandin induction and suction curettage. Restoration of ovulation Plasma progesterone samples were obtained from 29 patients, of whom 24 had been pregnant at the time of the procedure. Their plasma progesterone levels are illustrated in Fig. 1. By the 21st postoperative day, only 3 patients had values above 16 nmol/l (5 nglml), suggesting ovulation. Four additional patients showed somewhat less elevated values. Of all pregnant patients, 17 % had a rise in BBT suggesting possible ovulation by the 21st postoperative day. This observation fits with the onset of their first menstruation after the menstrual regulation procedure. Approximately 60% of all pregnant patients had their first menstruation before the 40th postoperative day. The mean procedure-menstruation interval was 37 days, range 21-65 days.
DISCUSSION
1
0
1
14
21
DAYS
Fig. 1. Plasma progesterone concentrations after the procedure (logarithmic scale).
In this study on 116 women with documented or suspected pregnancy evacuated with a standard Vabra aspirator, the success rate was 97%, while the total complication rate was 6.8%. Similar studies from other centres show a total complication rate of between 0.2 and 11.0% (14), being in general of the same order as in standard vacuum extraction techniques used in later first trimester abortion (13, 15). Acta Obsrrt Gynccol Scand 58 (1979)
172
M . Mandelin and 0 .Karjalainen
Some 10% of the women applying for MR procedure were not pregnant, thus representing the group undergoing an unnecessary operation. This percentage is lower than generally reported (lo), possibly due to the fact that the majority (70%) of the patients were more than 13 days overdue. It is possible that referring doctors were more liable to send patients with positive pregnancy tests. The use of more sensitive tests will naturally minimize the possibility of unnecessary procedures. A disadvantage of this method is that the detection of extrauterine pregnancies is rather difficult. The histopathologic diagnosis of decidual reaction may as well be due to a failure in the evacuation procedure as to extrauterine pregnancy or, as shown in this series, to a failure in tissue processing for histology. Therefore, a histological diagnosis of decidual reaction calls for very close follow-up. In our opinion, menstrual regulation always demands a histopathological examination of the aspirated tissue. A thorough follow-up is necessary also in order to reveal possible failures, another problem hardly encountered with conventional abortion technique. To reduce failure incidence, it may be advisable to wait until the patients are at least 14 days overdue, as all the failures in this series occurred in patients whose menses delay was shorter than that. Most MR studies have been done using soft Karman plastic cannulas. In this study a standard 3 mm Vabra aspirator was used but the rigid and relatively narrow cannula presented no problems. There were no perforations, and in the few cases where the cannula was blocked by tissue, the blockage was easily overcome by increasing the vacuum. The Vabra aspirator, which has a chamber for tissue collection, was found well suited for the purpose. Soft plastic cannulas, of course, reduce the risk of perforation. Boyd & Holmstrom (2) found in their series of conventional abortion that, on the basis of endometrial biopsy, about 50% of the patients had ovulated by the 22nd postoperative day. Although in this study the corresponding figure was only some 13%, some immediate postabortal contraception is nevertheless called for. In this series, there were 8 proven cases of ovum abortivum and 1 case of hydatiform mole, representing an 8.7% incidence of defective ova of the intrauterine pregnancies. This incidence was clearly lower than we expected on the basis of reActa Obstet Gynecol Scand 58 (1979)
ports by investigators involved in human fertility studies (9). Thus, the importance of pathologic ova as a cause of unnecessary artificial termination may not be of great significance. CONCLUSION The menstrual regulation type of pregnancy termination has some clear advantages compared with the standard VE procedure later in the first trimester. As a simple, rapid measure done in the earliest weeks of pregnancy, it reduces the emotional stress that is associated with the termination of an unwanted pregnancy in a later stage. It allows the patients to resume their normal activities immediately. Its complication rates are within reasonable limits and, combined with efficient follow-ups, it contributes very favourably to the management of unwanted pregnancies. REFERENCES 1. Atienza, M. F., Burkman, R. T., King, T. M., Burnett, L. S., Lau, H. L., Parmley, T. M. &
Woodruff, J. D.: Menstrual extraction. Am J Obstet Gynecoll21: 490, 1975. 2. Boyd, E. F. & Holmstrom, E. G.: Ovulation following therapeutic abortion. Am J Obstet Gynecol 113: 469, 1972. 3. Brenner, W. E., Edelman, D. A. & Kessel E.: Menstrual regulation in the United States: A preliminary report. Fertil Steril26: 289, 1975. 4. Bygdeman, M., BoreU, U., Leader, A., Lundstriim, V., Martin, J. N . & Eneroth, P.: Induction of first and second trimester abortion by the vaginal administration of 15-methyCPGF,-methyl ester. I n Advances in Prostaglandin and Thromboxane Research (eds. B. Samuelson & R. Paoletti), vol. 2, p. 693. Raven Press, New York, 1976. 5 . Devilla, G. O., Jr., Roberts, K., Wiest, W.G., Mikhail, G. & Flickinger, G.: A specific radioimmunoassay of plasma progesterone. J Clin Endocrinol Metab 35: 458, 1972. 6. Janne, O., Apter, D. & Vihko, R.: Assay of testosterone, progesterone and 17a-hydroxyprogesterone in human plasma by radioimmunoassay on hydroxyalkoxypropyl Sephadex. J Steroid Biochem 5: 155, 1974. 7. Karman, H. & Potts, M.: Very early abortion using syringe as vacuum source. Lancet 1: 1051, 1972. 8. Lancet, Editorial, p. 947, May 1976. 9. Leridon, H.: Dkmographie des Cchecs de la reproduction. I n Les Accidents Chromosomiques de la Reproduction (eds. A. BouC & C. Thibault), p. 13. INSERM, Paris, 1973. 10. Miller, E. R., Fortney, J. A. & Kessel, E.: Early vacuum aspiration: Minimizing procedures to nonpregnant women. Fam Plan Perspect 8: 33, 1976.
Menstrual regulation 11. Purola, E. & Nerdrum, T.: Re-establishment of menstruation after abortion. Ann Chir Gynaecol Fenn 57:618, 1968. 12. Ross, G. T., Cargille, C. M., Lipsett, M. B., Rayfard, P. L., Marshall, J. R., Strott, C. A. & Rodbard, D.: Pituitary and gonadal hormones in women during spontaneous and induced ovulatory cycles. Rec Prog Horm Res 26: 1, 1970. 13. Sigurdsson, K.: Aborter vid Nacka sjukhus 1975-somatiska komplikationer och preventivteknik. Sv. Lakartidningen 74: 318, 1977. 14. Stringer, J., Anderson, M., Beard, R. W.,Fairweather, D. V. I. & Steele, s. J.: Very early termination of pregnancy (menstrual extraction). Br Med J 3:7, 1975.
173
15. Tietze, C. & Murstein, M. C.: Abortion Factbook
1975, Reports on PopulationtFamity Planning No. 14, 2nd ed., December. 16. Van der Vlugt, T. & Piotrow, P. T.: Menstrual regulation update. Population Report, Series F, No.4, May 1974. Submitted for publication Jan. 17, 1978
Matti Mandelin Department of Obstetrics and Gynecology I and I1 University Central Hospital Helsinki Finland
Actn Obstet Gynecol Sccind 58 (1979)
