Acta Obstet Gynecol Scand 57: 237-240, 1978

THERAPEUTIC ABORTION The 1975 report from Ullevdl Hospital Fritjof Jerve and Petter Fylling From the Department of Obstetrics and Gynecology, UllevLil Hospital, Oslo, Norway

Abstract. The results from a prospective study of 1228 therapeutic abortions (the 1975 material) are reported. First trimester pregnancies (1 028 cases) were terminated by suction and curettage and second trimester pregnancies by prostaglandins (200 cases). The overall follow-up (4-6 weeks after termination) was 94.3%. The incidence of perforation was 0.5 % o f the surgical terminations, none of which, however, resulted in any other complications. The mean incidence of re-admission was 3.9%, the main causes being retained products or pelvic infection. The mean incidence of pelvic infection (salpingitisl parametritis) was 1.6%. The highest incidence of pelvic infection was found in early pregnancies ( 4 weeks) or nulliparous women (2.7%) and the lowest (1.5%) in the induction group.

Surgical complications associated with therapeutic abortion have gradually decreased during the last decade. This trend is concurrent with the increase in the number of therapeutic abortions performed, improvement of the techniques and greater experience and training of medical personnel in this special field (2, l l , 13, 18, 19, 22, 23). Hence, prospective studies for limited periods and a certain homogeneity of the staff involved, should give a more reliable picture of the current situation in each centre or region. Our 1975 material on therapeutic abortion, based on recording each step of the treatment procedure on EDB-forms specially designed for this purpose, is reviewed. MATERIAL AND METHODS The series consists of 1228 pregnancies that were terminated at our clinic in 1975. All women underwent gynaecological examination at our outpatient clinic 1-7 days prior to the termination. The majority of the women were examined by one of us (P.F.). At this initial visit the medical history was recorded and the size of the uterus estimated. Samples for the relevant laboratory tests such as Rh, etc. were also secured at this visit.

Based on the size of the uterus the women were divided into 2 groups. The first group included nulliparous women 1 1 weeks pregnant and parous women s 12 weeks pregnant. The second group included all second trimester pregnancies and also nulliparous women 12 weeks pregnant. The first group was treated on an outpatient basis by a surgical method. A few patients in this group were admitted to hospital for simultaneous sterilization or because of pregnancies complicated with medical disorders such as diabetes, etc. The second trimester pregnancies were terminated by induction. Surgicalprocedure. The women attended the outpatient clinic in fasting condition at 8 o’clock a.m. and the terminations were performed under i.v. anaesthesia by cervical dilation and vacuum aspiration. As a general rule a vacuum metal aspiration curette No. 8 was used up to 9-10 weeks and No. 10 after 9-10 weeks. The women were observed 3-4 hours postoperatively and then discharged from the hospital. Induction of abortion. All inductions were performed by prostaglandins. Different methods were used as parts of clinical trials administered by the Prostaglandin Task Force, Karolinska Institutet, Stockholm. Eighteen women underwent sterilization simultaneously with the termination (4 by laparotomy and 14 by laparoscopy). Vaginal bacteriological screening was not performed as a routine. No pregnancies were terminated by hysterotomy and Gammaglobulin was given to all Rhnegative women. Follow-up. On discharge from the hospital all women were given an appointment for a follow-up visit and written instructions which emphasized the importance of control. If a woman failed to keep this appointment about 4 weeks later, she received a new one by mail. If she still did not appear, she was given a third chance by filling in a questionnaire which was sent to her by mail. The data recorded were handled by the municipal EDB-department.

RESULTS The distribution of the material according to agegroups is illustrated in Fig. I . As many as 24.2 % of

F . Jerve and P. Fylling

238

14501 L J

1

750

U no.

in each group

1

1 I

400.

w no

no. followed up 5300.

-5

3 200

b71

followed UP

7

*

0

L 100 * n

C

-

520

21-25

26-30

31-35

365

years

58

Fig. I . Distribution of the material in age-groups. The total number in each group is indicated in the parentheses.

the women were less than 21 years old and 36.4% were between 21 and 25 years old. As shown in Fig. 2 the majority of the pregnancies (76.4 %) were terminated within the first 10 weeks of gestation and 61.1% of the women were nulliparous. The main peroperative complications are listed in Table 1, but none of them were serious. None of the 5 uterine perforations, i.e. 0.5 per cent of the surgical terminations, resulted in any other immediate or late (4-6 weeks) complications. Patients with uterine perforations were observed in the hospital overnight and then discharged. Although the figures are small, they might indicate a certain percentage increase in the incidence of perforations with increasing gestational length. As may be expected, a higher incidence of cervical laceration was observed in the nulliparous group. However, the lacerations were always of minor degree and did not necessitate any treatment. The bleeding recorded in 12 patients, was also of moderate degree and blood transfusion was given in only one case, a prostaglandininduced abortion. Fig. 3 shows the incidence of re-admission or pelvic infection related to age-groups or parity. By far the highest incidences of both re-admission and

9-10

11-12

weeks

135 parity

Fig. 2 . Distribution of the material in gestational length or parity. The total number in each group is indicated in the parentheses.

pelvic infection were found among young (s20 years) or nulliparous women. Fig. 4 illustrates the incidence of re-admission or pelvic infection related to gestational length and methods used. Contrary to what was expected, the percentage highest incidence of pelvic infection was found in the G8 weeks group while in the induction group (200 cases) only 3 cases were observed. These 3 cases were nulliparous women and one of them was 12 weeks and the 2 others were 13 weeks pregnant. The percentage re-admission seems to be a fairly good indicator of the quality of the technical procedure. In Table I1 the percentage of re-admission related to the different medical officers is illustrated. The clinical and technical experience of the medical officers A-C was greatest and that of G-I was least. Bleeding, pain or fever were the most common symptoms causing re-admission. Folbv-up. I108 or 90.2% of the women appeared at the follow-up visit and 50 replied to questionnaires. Hence, we obtained postoperative information on totally 94.3% of the material. The postoperative period varied from 4 to 8 weeks, mostly 4 to 5 weeks.

Table I. Peroperative complications related t o gestutional length or parity Gestational length in weeks

Perforation Laceration of the cervix Bleeding

Parity

s8

9-10

11-12

13s

0-Parous

Parous

Total

3 (0.6%)

1(0.2%)

1 (1.0%)

0

4 (0.6%)

1 (0.2 %)

5 (0.5 %)

1 (0.2%) 2 (0.4%)

1 (0.2%) 3 (0.6%)

0

1(1.0%)

5 (2.6%)

0

3 (0.4%) 5 (0.7%)

0 5 (1.0%)

3 (0.2%) 10 (0.8%)

Therapeutic abortion

239

out of the 5 perforations occurred in cases of early pregnancy ( s 8 weeks). It is reasonable to assume 5 that this complication, at least in the 8 weeks 1 4 group, could be avoided by using Karman cannulae c (10, 15). On the other hand, a higher incidence of $ 3 retained products is reported using plastic cannulae n 2 compared with metal ones (3). Exact quantitation of peroperative bleeding was 1 not performed in the present series. Bleeding “more 0 than usual” was recorded as “bleeding”. In only 0 21 mean $20 21-25 26-30 31-35 365 one case, a second trimester abortion induced by parity years prostaglandins, the bleeding necessitated a blood transfusion. Fig. 3. The incidence of re-admission or pelvic infection (salpingitislparametritis)related to age-groups or parity. Other peroperative complications were also relatively few, especially in the second trimester group, compared with some previous reports (2,6-8, 11, 13, 19, 22, 23). As already reported by several inDISCUSSION vestigators, reviewed by Brenner (4), induction of second trimester abortion by prostaglandins is The present material is similar to some previous superior to other methods for termination. Hence, reports concerning age and parity (3, 15, 19,23). Intravenous administration of Brietal Natrium@, surgical termination of pregnancies beyond the 12th “Lilly”, was found to be a very suitable anesthesia week should be avoided. However, the intermediate for this type of surgery. We recorded a low group (10-11 weeks), might still be terminated by percentage of discomfort among patients shortly vacuum aspiration, eventually combined with after the procedure. Although we are aware of the preoperative prostaglandin treatment. The figures for post-termination complications widespread use of local anesthesia for this type of will obviously be dependent on 1) the criteria used surgery (1, 9, 15, 19) at least in our hands, i.v. in the assessment of complications, 2) the evaluaanesthesia seems to be preferable because of the anxiety for the procedure usually experienced by tion techniques used, and 3) the observation period. The highest incidence of salpingitislparametritis the women in our population. We found relatively few perioperative complica- was observed in the 4 weeks group and this was tions in the present material. The figures for perfo- entirely unexpected. At least 3 possibilities exist: ration (0.5%) are higher than those reported by ( a ) it is more ditficult to empty the cavity comsome others (6, 9, 12, 16, 17, 19), but none of the pletely in this group, ( 6 ) the medical officer “may perforations caused any additional damage. Three consider” the procedure to be easier in this group and hence, might not be vigilant enough during the 0 re-admission vacuum aspiration procedure, ( c )some factors, like pelvic infection high sexual activity, causing a higher prevalence of n n pelvic infections in this group. Of a total of 20 cases with pelvic infection in the 4 group as many as 17 were nulliparous. Hence, in the authors’ opinion, a combination of causes is a reasonable explanation 6

0

-

re-admission pelvic infection

n

(Y

58

9-10

13s

11-12 weeks

I

V. A.

surg. methods

P.G. ind.

mean

I

I P.G.

ind.

Fig. 4. The incidence of re-admission or pelvic infection (salpingitis/parametritis) related to gestational length and V . A .=vacuum aspirations; P . G . methods used. ind. = prostaglandin-induced abortions.

Table I I . Percenttrge re-ciclinissiot.~per. t n e d i c d Jicer

i$

Medical officer

A

Re-admission

3.0 3.2 3.3 4.0 4.2 4.7 4.8 5.0 5.9

B

C

D

E

F

G

H

I

240

F . Jerve and P . Fylling

for the higher incidence of pelvic infection in early pregnancy. The policy has been to terminate the pregnancies as early as possible as this has proved beneficial both from a psychological and somatic point of view (14, 19,20). Since the present methods for terminating early pregnancies, at least in our hands, do not appear to be so satisfactory as anticipated, greater efforts must now be made to improve these procedures.

ACKNOWLEDGEMENT This investigation received financial support from the World Health Organization.

REFERENCES I . Bendel, R. P., Williams, P. P. & Butler, J. C.: Endometrial aspiration in fertility control. A report of 500 cases. Am J Obstet Gynecol125: 328, 1976. 2. Berthelsen, H.G. & gstergaard, E.: Techniques and complications of therapeutic abortion. Danish Med Bull6: 105, 1959. 3. Borko, E., Breznik, R., Kokos, Z., Edelman, D. & Brenner, W.: First trimester abortion by vacuum aspiration. Ann Chir Gynaecol Fenniae 64:320, 1975. 4. Brenner, W. E.: The current status of prostaglandins as abortifacients. Am J Obstet Gynecol 123:306, 1975. 5. Brenner, W. E., Edelman, D. A. & Kessel, E.: Menstrual regulation in The United States. A preliminary report. Fertil Steril26: 289, 1975. 6. Edelman, D.A., Brenner, W. E. & Berger, G. S.: The effectiveness and complications of abortion by dilatation and vacuum aspiration versus dilatation and rigid metal curettage. Am J Obstet Gynecol119:473, 1974. 7. Fylling, P. & Refsdai, A,: Rivanol-induced midtrimester abortion. Arch GynakZIS: 359, 1973. 8. Fylling, P. & Refsdal, A.: Therapeutic abortion by a single extra-amniotic instillation of prostaglandin F2a. Arch Gyniik217: 119, 1974. 9. Golditch, I. M. & Glasser, M. H.: The use of laminaria tents for cervical dilatation prior to vacuum

Actti Obstet Cvnecol Scund57 (1978)

aspiration abortion. Am J Obstet Gynecol 119: 481, 1974. 10. Johnstone, F. D., Beard, R. J., Boyd, I. E. & McCarthy, T. G.: Cervical diameter after suction termination of pregnancy. Br Med J I : 68,1976. 11. Kerenyi, T. D., Mandelman, N. & Sherman, D. H.: Five thousand consecutive saline inductions. Am J Obstet Gynecol116: 593, 1973. 12. Kerslake, D.: Abortion induced by means of the uterine aspirator. Obstet Gynecol SO: 35, 1967. 13. Kolstad, P.: Therapeutic abortion. Acta Obstet Gynecol Scand34: Suppl. 6, 1957. 14. Lebensohn, 2. M.: I n Abortion Techniques and Service (ed. S. Lewit), p. 55, Exerpta Medica, Amsterdam, 1972. IS. Lewit, S. C., Lal, S., Branch, B. & Beard, R. W.: Outpatient termination of pregnancy. Br Med 5 4 : 606, 1971. 16. Moberg, P. J.: Uterine perforation in connection with vacuum aspiration for legal abortion. Int J Gynecol Obstet 14: 77, 1976. 17. Nathanson, B. M.: Management of uterine perforations suffered at elective abortion. Am J Obstet Gynecol119: 473, 1974. 18. Potts, D. M.: Termination of pregnancy. Br Med Bull 26: 65, 1970. 19. Rovinsky, J. J.: Abortion in New York City. Preliminary experience with a permissive abortion statute. Obstet Gynecol38: 333, 1971. 20. Russel, K. P.:I n Abortion Techniques and Service (ed. S. Lewit), p. 12. Exerpta Medica, Amsterdam, 1972. 21. Spivak, M. M.: Therapeutic abortion. A 12-year review at the Toronto General Hospital, 1954-1965. Am J Obstet Gynecol97: 316,1976. 22. Stewart, G. K.& Goldstein, P.: Medical and surgical complications of therapeutic abortions. Obstet Gynecol40: 539, 1972. 23. Tietze, C. & Lewit, S.: I n Abortion Techniques and Service (ed. S. Lewit), p. 42. Exerpta Medica, Amsterdam, 1972. Submitted for publication Febr. 16, 1977

Fri tj of Jerve Department of Obstetrics and Gynecology Ullevhl Hospital Oslo Norway

Therapeutic abortion. The 1975 report from Ullevål Hospital.

Acta Obstet Gynecol Scand 57: 237-240, 1978 THERAPEUTIC ABORTION The 1975 report from Ullevdl Hospital Fritjof Jerve and Petter Fylling From the Depa...
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