Therapeutic abortion with concurrent sterilization: comparison of methods

Among patients seeking abortion are a group who request concurrent sterilization. This study compared three combinations of abortion and sterilization techniques. Suction termination with laparoscopic tubal ligation appears to be the combination of choice, for the mean hospital stay of patients undergoing this procedure was two days and the operative morbidity was 3.1%. For suction termination with tubal ligation at laparotomy, and hysterotomy with tubal ligation the mean hospital stays were 6 and 5.7 days respectively and the operative morbidity was four to five times greater.     

Midtrimester abortion induced by serial intravaginal administration of prostaglandin E2 suppositories in conjunction with a contraceptive diaphragm.

Midtrimester abortion was successfully induced in 68 of 69 patients with serial intravaginal administration of prostaglandin E2 suppositories behind a contraceptive diaphragm. The mean abortion time for the successful inductions was 13.07 hours; multiparous patients aborted somewhat faster, mean 12.72 hours, as compared to nulliparous patients, mean 14.22 hours. In 36 patients the PGE2 suppositories were placed behind an intact diaphragm and the mean abortion time was 14.89 hours. In 33 patients the PGE2 suppositories were placed behind a diaphragm modified by having an opening incised in the center, the mean time in these patients was 11.96 hours. Of the 68 successful abortions 59% of the patients aborted in 12 hours or less and 88% aborted within 24 hours. The most frequently encountered side effect was temperature elevation of 2 degrees F or higher which occurred in 68% of the patients. Temperatures returned to normal levels within 4 to 6 hours after the last adminstration of PGE2. Gastrointestinal side effects occurred in 45% of patients, but these side effects were well tolerated and did not require termination of drug administration in any of the patients. Intravaginal administration of PGE2 suppositories is a very effective abortifacient technque during the midtrimester, however the use of PGE2 in conjunction with a diaphragm did not appreciabley improve the technique although the amount of drug administered and the incidence of side effects was somewhat lower than when the PGE2 suppositories are used alone. If a diaphragm is to be used, a modified diaphragm is indicated since it simplifies the clinical management of the abortion, eases administration of the suppositories and permits a more accurate estimation of cervical changes, vaginal bleeding and abortion.     

CMA abortion survey.

Responses to the question as to whether abortions should be performed at the woman''s request during the first trimester of pregnancy were evenly divided. There was support for abortion on socioeconomic grounds, during the first trimester, from 61.5% of the respondents. Termination of pregnancy beyond the first trimester was supported by a majority of the respondents only in cases in which the woman''s life is in danger (73.9%) or in which there is evidence of a severe physical abnormality in the fetus (70.6%) or in cases in which the woman''s physical health is in danger (55.5%). Those who said they would not support abortion under any circumstances constitute, at most, 5.1% of the respondents. Support for the maintenance or the elimination of therapeutic abortion committees was addressed in two questions and in both cases the respondents were evenly divided. The responses to these two questions were compared and found to be logically consistent. Only physicians should perform abortions, and they should be performed in hospitals with the woman either as an inpatient or, during the first trimester, as an outpatient. The performance of first-trimester abortions in provincially approved abortion clinics was supported by 47.3% of the respondents. Of the 885 respondents who wished to see some amendment to the Criminal Code, 409 stated that the term "health" as used in the Criminal Code relative to the legal grounds for therapeutic abortion should be defined.     

Listeria monocytogenes in spontaneous abortions in humans and its detection by multiplex PCR

AIM: To assess the extent of Listeria monocytogenes in causation of human spontaneous abortions by isolation methods and PCR analysis for the presence of virulence-associated genes. METHODS AND RESULTS: A total of 305 samples comprising blood, urine, placental bits, faecal and vaginal swabs were collected from 61 patients with spontaneous abortions. Listeria spp. were isolated from 10 samples collected from nine (14.8%) patients. Confirmation of these isolates was based on biochemical tests, haemolysis on blood agar, CAMP test, phosphatidylinositol-specific phospholipase C (PI-PLC) assay followed by in vivo pathogenicity tests and multiplex PCR to detect virulence-associated genes (prfA, plcA, hlyA, actA and iap). Three isolates were confirmed as L. monocytogenes. Of these, two isolates turned out to be pathogenic and found to posses all five genes. However, the remaining two haemolytic L. monocytogenes isolates lacking the plcA gene and activity in the PI-PLC assay were found to be nonpathogenic by in vivo tests. CONCLUSIONS: The occurrence of pathogenic L. monocytogenes in cases of spontaneous abortions was 3.3%. It seems that the plcA gene and its expression have an important role as essential virulence determinants in pathogenic Listeria spp. SIGNIFICANCE AND IMPACT OF THE STUDY: The recovery of pathogenic L. monocytogenes isolates from cases of spontaneous abortion indicates the significance of listeric infection in pregnant women.     

Legal abortions among teenagers in Canada, 1974 through 1978.

Between August 1969, when the amendment to the Criminal Code went into effect, and December 1978 about 397 000 legal abortions were performed in hospitals with therapeutic abortion committees in Canada. During the 5-year period 1974-78 abortions in females under 20 years of age accounted for 30.9% of all the legal abortions performed in Canada on Canadian residents, and the abortion rate per 1000 women aged 15 to 19 years increased from 13.6 to 16.3. During 1974-77 the proportion of women in whom the gestation period was more than 12 weeks at the time of abortion was 25.3% for teenagers (females under 20 years of age) but only 14.6% for women aged 20 years or over. In 1976 the teenage abortion rate was lower in Canada (14.5) than in the United States (36.2%), Sweden (28.5), Hungary (26.4), Denmark (26.0), Norway (22.7), Finland (20.3), and England and Wales (15.4).     

Midtrimester abortion induced by serial intravaginal administration of prostaglandin E2 suppositories in conjunction with a contraceptive diaphragm

Midtrimester abortion was successfully induced in 68 of 69 patients with serial intravaginal administration of prostaglandin E₂ suppositories behind a contraceptive diaphragm. The mean abortion time for the successful inductions was 13.07 hours; multiparous patients aborted somewhat faster, mean 12.72 hours, as compared to nulliparous patients, mean 14.22 hours. In 36 patients the PGE₂ suppositories were placed behind an intact diaphragm and the mean abortion time was 14.89 hours. In 33 patients the PGE₂ suppositories were placed behind a diaphragm modified by having an opening incised in the center, the mean time in these patients was 11.96 hours. Of the 68 successful abortions 59% of the patients aborted in 12 hours or less and 88% aborted within 24 hours. The most frequently encountered side effect was temperature elevation of 2° F or higher which occurred in 68% of the patients. Temperatures returned to normal levels within 4 to 6 hours after the last administration of PGE₂. Gastrointestinal side effects occurred in 45% of patients, but these side effects were well tolerated and did not require termination of drug administration in any of the patients. Intravaginal administration of PGE₂ suppositories is a very effective abortifacient technique during the midtrimester, however the use of PGE₂ in conjunction with a diaphrgam did not appreciabley improve the technique although the amount of drug administered and the incidence of side effects was somewhat lower than when the PGE₂ suppositories are used alone. If a diaphragm is to be used, a modified diaphragm is indicated since it simplifies the clinical management of the abortion, eases administration of the suppositories and permits a more accurate estimation of cervical changes, vaginal bleeding and abortion.     

Barriers to Rural Induced Abortion Services in Canada: Findings of the British Columbia Abortion Providers Survey (BCAPS)

Background

Rural induced abortion service has declined in Canada. Factors influencing abortion provision by rural physicians are unknown. This study assessed distribution, practice, and experiences among rural compared to urban abortion providers in the Canadian province of British Columbia (BC).

Methods

We used mixed methods to assess physicians on the BC registry of abortion providers. In 2011 we distributed a previously-published questionnaire and conducted semi-structured interviews.

Results

Surveys were returned by 39/46 (85%) of BC abortion providers. Half were family physicians, within both rural and urban cohorts. One-quarter (17/67) of rural hospitals offer abortion service. Medical abortions comprised 14.7% of total reported abortions. The three largest urban areas reported 90% of all abortions, although only 57% of reproductive age women reside in the associated health authority regions. Each rural physician provided on average 76 (SD 52) abortions annually, including 35 (SD 30) medical abortions. Rural physicians provided surgical abortions in operating rooms, often using general anaesthesia, while urban physicians provided the same services primarily in ambulatory settings using local anaesthesia. Rural providers reported health system barriers, particularly relating to operating room logistics. Urban providers reported occasional anonymous harassment and violence.

Conclusions

Medical abortions represented 15% of all BC abortions, a larger proportion than previously reported (under 4%) for Canada. Rural physicians describe addressable barriers to service provision that may explain the declining accessibility of rural abortion services. Moving rural surgical abortions out of operating rooms and into local ambulatory care settings has the potential to improve care and costs, while reducing logistical challenges facing rural physicians.     

Amitriptyline: initial intolerance and subsequent psychosis.

Both posterior colpotomy with associated fimbriectomy and laparoscopy offer rapid and effective methods for carrying out interim and post-abortion tubal sterilization. They can effectively be performed on an out-patient basis. Posterior colpotomy has the added advantage that it can be conveniently performed under a combination of intravenous neuroleptanalgesia and local vaginal anesthesia. This series exemplifies the manner in which the burden upon hospital facilities and medical and paramedical personnel can be minimized. In addition, utilization of the “home-care program” has improved patient acceptance and convenience.     

Abortion in Sows

Of a total of 31,766 pregnancies 465 abortions were reported, in average 1.46 %. By comparison of the frequency of abortion at different times of the year a significantly higher percentage of abortion was found in sows inseminated during the summer months. No significant difference was found between 68 boars as to the frequency of abortion. In 248 abortions 23 (9.3 %) aborted due to acute erysipelas suis, 5 due to non-infectious diseases, 4 due to spoiled food, but 216 (87.0 %) sows aborted without any previous symptoms.     

Effects of legal termination on subsequent pregnancy.

Two hundred and eleven patients who had undergone vaginal termination and were pregnant again were investigated; 43-2% had become pregnant within one year of termination. The overall fetal loss in the 211 patients was 17-5% compared with 7-5% in a group matched for parity but consisting of patients who were pregnant after a spontaneous abortion. Altogether 4-3% of pregnancies after legal abortion ended as first trimester abortions, 8-5% as second trimester abortions, and 13-7% in premature delivery. Among 11 women whose cervices had been lacerated at the time of legal termination the fetal loss in subsequent pregnancy was 45-5%, and only one pregnancy went beyond 36 weeks. Routine Shirodkar suture may be beneficial when the cervix is known to have been damaged at legal abortion. Several patients had asked that their general practitioner should not be told of their termination, and such patients may not admit their termination during a subsequent pregnancy, which could thus be jeopardised. No evidence was found to suggest that infants of patients with a history of legal termination are small for dates.     

Incidence of hysterectomy and tubal ligation in public hospitals in south Australia, 1980-82

Physicians performed 3866 hysterectomies and 5622 tubal ligations in South Australian public hospitals between 1980 and 1982. Data did not indicate if the hysterectomies occurred for medical reasons or for sterilization, though, but for women less than 40 years of age the procedure could have been used to prevent childbearing. 83% of the women in the study were currently married. Average annual incidence rates for women aged 15 and older were 773 hysterectomies and 1125 tubal ligations per 100,000 women. 54% of the women who had a hysterectomy were less than 45 years old. Median age for women who experienced a hysterectomy was 44, as for those who had a tubal ligation the median age was 32. Most women (60%) who underwent a tubal ligation were between 25-34 years old, and 8% were younger than 25 years old. Women born overseas comprised 37% of women who had a hysterectomy and 31% of those who had a tubal ligation. The highest age-specific hysterectomy rate occurred in the 45 to 49 age group whereas the sterilization rate peaked at the 30 to 34 range. Based on only the public hospital data, researchers estimated that women in South Australia had a 1 in 6 chance of having a hysterectomy and a 1 in 5 chance of undergoing a tubal ligation. Further research is needed to learn why women choose to have elective surgery when it is not medically necessary. The possibility exists that they choose it over oral contraceptives because of the adverse publicity they have received.     

Factors associated with immediate abortion complications.

OBJECTIVE: To identify factors associated with increased risk of immediate complications from induced abortion. DESIGN: Retrospective analysis of a provincial database. SETTING: All Ontario general hospitals in which abortions are performed and all free-standing abortion clinics in Ontario. POPULATION: Women in Ontario aged 15 to 44 years who underwent an induced abortion in the province (without concurrent sterilization) between Jan. 1, 1992, and Dec. 31, 1993. OUTCOME MEASURES: Recording of complications at the time of the procedure, gestational age, type of procedure, place of abortion (hospital or clinic), and patient''s age, parity and history of previous abortion (spontaneous or induced). RESULTS: During the study period 83 469 abortions were performed that met our inclusion criteria. Immediate complications were reported in 571 cases (0.7%). Multivariate logistic regression analysis revealed that, after other variables were controlled for, the patient''s age, parity and history of previous abortions (spontaneous or induced) were not significant risk factors for immediate complications; however, gestational age, method of abortion and place of abortion were significant risk factors (p < 0.001). The odds ratio (OR) for having a complication from abortion was 1.3 (95% confidence interval [CI] 1.02 to 1.63) between 9 and 12 weeks, compared with having one after abortion at 9 weeks or earlier, and increased to 3.3 (95% CI 2.23 to 5.00) after abortion between 17 and 20 weeks. Compared with surgical dilatation and curettage (D&C), instillation of saline and instillation of prostaglandins were more likely to be associated with immediate complications (OR 24.0, 95% CI 13.22 to 43.70, and OR 11.7, 95% CI 6.43 to 21.18, respectively), whereas both suction D&C and insertion of a laminaria tent were less likely to be associated with immediate complications (OR 0.4, 95% CI 0.26 to 0.67, and OR 0.3, 95% CI 0.19 to 0.52, respectively). Compared with women who had an abortion in a free-standing clinic, the risk for immediate complications was greater among those who had an abortion in a hospital, especially a teaching hospital (OR 1.9, 95% CI 1.38 to 2.58), a nonteaching hospital with 200 to 399 acute care beds (OR 3.1, 95% CI 2.27 to 4.21) and a nonteaching hospital with fewer than 200 acute care beds (OR 5.9, 95% CI 4.04 to 8.64). CONCLUSION: The risk of immediate complications from induced abortion is very low. Unlike in previous studies, the woman''s age, parity and history of previous spontaneous or induced abortions were not found to be risk factors. However, advancing gestational age and procedures involving instillation of saline or prostaglandins were predictive factors of immediate complications.     

Risks and costs of illegally induced abortion in Bangladesh

This article reports on women admitted to Dhaka Medical College Hospital for incomplete, illegally induced abortion. Women with low complication rates more often had abortions induced by medical practitioners. These women were younger, of lower parity and better educated than women having abortions initiated by other practitioners. Poorly educated women from slum areas almost always had an abortion induced by a nonmedical practitioner through the insertion of a solid object. These women experienced high complication rates and often required hysterectomies. This group also had high mortality rates. The drain on hospital resources needed to treat these abortion patients was great.     

Therapeutic Abortion in a Canadian City

In a city of 200,000, 119 therapeutic abortions were performed during the period 1962 to 1968. Multiple grounds were commonly given for abortion; these often included depression. Very frequently the absence of support from other people was a factor in deciding to perform abortion. Only five psychiatrists were involved in 82 cases seen in psychiatric consultation. Abortions carried out for more conventional medical reasons, including rubella, decreased in 1967 and 1968 but there was an overall increase beginning in 1967. In the later years of the study (1967-68) a higher proportion of patients were single, younger, had had no previous pregnancy and were aborted later in pregnancy; more were sterilized.A marked increase in abortion rate related particularly to the activity of one of the psychiatrists.One hundred and sixty-six abortions were performed in 1969; a comparable figure (179) was obtained from one other Canadian centre; another centre had performed more (291); two others, 109 and 63; the combined total for 27 other centres from whom replies were obtained was 186.     

Lawful Sinners: Reproductive Governance and Moral Agency Around Abortion in Mexico

The Catholic Hierarchy unequivocally bans abortion, defining it as a mortal sin. In Mexico City, where the Catholic Church wields considerable political and popular power, abortion was recently decriminalized in a historic vote. Of the roughly 170,000 abortions that have been carried out in Mexico City's new public sector abortion program to date, more than 60% were among self-reported Catholic women. Drawing on eighteen months of fieldwork, including interviews with 34 Catholic patients, this article examines how Catholic women in Mexico City grapple with abortion decisions that contravene Church teachings in the context of recent abortion reform. Catholic women consistently leveraged the local cultural, economic, and legal context to morally justify their abortion decisions against church condemnation. I argue that Catholic women seeking abortion resist religious injunctions on their reproductive behavior by articulating and asserting their own moral agency grounded in the contextual dimensions of their lives. My analysis informs conversations in medical anthropology on moral decision-making around reproduction and on local dynamics of resistance to reproductive governance. Moreover, my findings speak to the deficiencies of a feminist vision focused narrowly on fertility limitation, versus an expanded framework of reproductive justice that considers as well the need for conditions of income equality and structural supports to facilitate reproduction and parenting among women who desire to keep their pregnancies.     

Incidence of Induced Abortion in Uganda, 2013: New Estimates Since 2003

BackgroundIn Uganda, abortion is permitted only when the life of a woman is in danger. This restriction compels the perpetuation of the practice in secrecy and often under unsafe conditions. In 2003, 294,000 induced abortions were estimated to occur each year in Uganda. Since then, no other research on abortion incidence has been conducted in the country.MethodsData from 418 health facilities were used to estimate the number and rate of induced abortion in 2013. An indirect estimation methodology was used to calculate the annual incidence of induced abortions ─ nationally and by major regions. The use of a comparable methodology in an earlier study permits assessment of trends between 2003 and 2013.ResultsIn 2013, an estimated 128,682 women were treated for abortion complications and an estimated 314,304 induced abortions occurred, both slightly up from 110,000 and 294,000 in 2003, respectively. The national abortion rate was 39 abortions per 1,000 women aged 15–49, down from 51 in 2003. Regional variation in abortion rates is very large, from as high as an estimated 77 per 1,000 women 15–49 in Kampala region, to as low as 18 per 1,000 women in Western region. The overall pregnancy rate also declined from 326 to 288; however the proportion of pregnancies that were unintended increased slightly, from 49% to 52%.ConclusionUnsafe abortion remains a major problem confronting Ugandan women. Although the overall pregnancy rate and the abortion rate declined in the past decade, the majority of pregnancies to Ugandan women are still unintended. These findings reflect the increase in the use of modern contraception but also suggest that a large proportion of women are still having difficulty practicing contraception effectively. Improved access to contraceptive services and abortion-related care are still needed.     

Transplacental passage of fetal red cells in abortion; increased incidence after curettage and effect of oxytocic drugs

In a study of early abortions (less than 16-week pregnancies) no significant increase in fetomaternal haemorrhage was found in patients having either threatened or incomplete abortions. A statistically significant increase in fetal cells in the maternal circulation, however, occurred after curettage. The administration of oxytocic drugs in conjunction with curettage in cases of incomplete abortion did not increase the incidence of transplacental passage of fetal erythrocytes when compared with curettage alone. Of the 81 patients curetted following abortion four had a feto-maternal haemorrhage of more than 0·2 ml. The largest amount of fetal blood found in the maternal circulation was 0·4 to 0·5 ml. Preliminary data evaluating the indirect Coombs test and enzyme-treated red cells in Rh-negative post-abortion cases suggest that this amount of blood is not a primary immunizing dose but a “booster” to preformed antibody.     

Pregnancy and the risk of autoimmune disease

Autoimmune diseases (AID) predominantly affect women of reproductive age. While basic molecular studies have implicated persisting fetal cells in the mother in some AID, supportive epidemiological evidence is limited. We investigated the effect of vaginal delivery, caesarean section (CS) and induced abortion on the risk of subsequent maternal AID. Using the Danish Civil Registration System (CRS) we identified women who were born between 1960 and1992. We performed data linkage between the CRS other Danish national registers to identify women who had a pregnancy and those who developed AID. Women were categorised into 4 groups; nulligravida (control group), women who had 1st child by vaginal delivery, whose 1st delivery was by CS and who had abortions. Log-linear Poisson regression with person-years was used for data analysis adjusting for several potential confounders. There were 1,035,639 women aged >14 years and 25,570 developed AID: 43.4% nulligravida, 44.3% had their first pregnancy delivered vaginally, 7.6% CS and 4.1% abortions. The risk of AID was significantly higher in the 1st year after vaginal delivery (RR = 1.1[1.0, 1.2]) and CS (RR = 1.3[1.1, 1.5]) but significantly lower in the 1st year following abortion (RR = 0.7[0.6, 0.9]). These results suggest an association between pregnancy and the risk of subsequent maternal AID. Increased risks of AID after CS may be explained by amplified fetal cell traffic at delivery, while decreased risks after abortion may be due to the transfer of more primitive fetal stem cells. The increased risk of AID in the first year after delivery may also be related to greater testing during pregnancy.     

Deliveries in teenagers at a Newfoundland general hospital.

A study of deliveries in teenagers was undertaken for the year 1975 in a hospital that had recorded 2797 births, 371 (13%) of which were to women under 20 years of age. Conception had occurred out of wedlock in 314 (85%) of the 371 pregnancies; 124 of the 314 women had married during the pregnancy, most often in the 3rd or 4th month of gestation. The peak months for conception out of wedlock were June and December. This was not the first pregnancy for 65 women (18%), 21 of whom had married during a previous pregnancy. Of the "heads of the households" 36% were labourers and 27% were unemployed. Cesarean section was the method of delivery for 51 (14%) of the women, and 63 (17%) were reported as having had toxemia. There were seven perinatal deaths and seven infants had severe congenital abnormalities. The frequency of low birth weight was 6% overall but 13% for the infants of single women. Five women underwent tubal ligation post partum.     

How Accurate Is Preoperative Evaluation of Pelvic Organ Prolapse in Women Undergoing Vaginal Reconstruction Surgery?

Objective

To evaluate the differences between the in-office and intraoperative techniques used to evaluate pelvic organ prolapse.

Materials and Methods

A prospective study included 25 women undergoing vaginal reconstruction surgery including vaginal hysterectomy for pelvic organ prolapse. The outpatient pelvic and site-specific vaginal examination was performed in the lithotomy position with the Valsalva maneuver. Repeated intraoperative examination was performed under general anesthesia with standard mild cervical traction. The Pelvic Organ Prolapse Quantification system (POPQ) was used for both measurements and staging. The values found under the two conditions were compared.

Results

The intraoperative POPQ-measurements values were significantly higher than the outpatient values for apical wall prolapse in 17/25 (68%) women and for anterior wall prolapse in 8/25 (32%) women. There was not a significant difference in the posterior wall where increase in staging was shown in 3/25 (12%) patients.

Conclusions

Clinicians and patients should be alert to the possibility that pelvic organ measurements performed under general anesthesia with mild traction may be different from preoperative evaluation.