Outpatient management of first trimester therapeutic abortions with and without tubal ligation

In busy hospitals the increasing numbers of abortions must be performed without disturbing other hospital functions. Local anesthesia, vaginal tubal ligation and the use of outpatient beds are the operative and administrative adaptations described. Of 1545 abortions performed in Victoria Hospital, London, in 1971, 428 (32%) were done under local anesthesia; 14 of these patients also had vaginal tubal ligation under local anesthesia. There were 405 sterilizations (26.2%) among this group of patients, of which 390 (96.3%) were vaginal tubal ligations. Of the total number, 891 (57.7%) were dealt with as outpatients and these comprised 62.0% of patients having therapeutic abortion only, and 46.7% of patients having tubal sterilization as well as abortion.     

Sterilization in Canberra

The discussion in this article uses data from the 1979 Canberra Population Survey to assess the degree and nature of the resistance to the use of sterilization, particularly male sterilization. In the 1979 Canberra Population Survey, respondents were asked what methods of contraception they would recommend to a couple who had completed their family. About 2/3 recommended sterilization, with vasectomy a more popular 1st choice, particularly for male respondents, than tubal ligation. Compared to 20% of the 1978 sample, 27% of the 1979 sample reported use of sterilization; the increase may reflect not only the increasing popularity of sterilization, but also improved reporting. The 1979 survey provides some confirmation of the forecast that 60% of Australian couples would use contraceptive sterilization as a method of birth control in their fertile lifetime. However, the forecast that the importance of vasectomy may come to equal that of tubal ligation seems highly unlikely, even though there seems to be some recognition by Canberra respondents that vasectomy is simple, safe and reliable. Data from the Canberra survey shows that although a majority of respondents would use sterilization, female sterilization would be preferred largely because men were more resistant to the idea than females. Other researchers have commented on the feeling that fertility decisions and contraception are ultimately the wife's concern. Respondents born outside Australia, the United Kingdom, and Eire were more resistant to the idea of sterilization, but reported higher use of tubal ligation. It is presently suggested that the choice of vasectomy or tubal ligation, or resistance to these methods, may in fact be important indicators of the assimilation of immigrants and of husband-wife communication of Australia. Future studies of sterilization in Australia might profit from focusing on sterilizationas an independent rather than a dependent variable.     

Induction of Therapeutic Abortion by Intra-amniotic Injection of Urea

A new method of mid-trimester termination of pregnancy is described in which intra-amniotic urea was used. The mean interval between intra-amniotic injection and abortion was 59 hours and the mean length of hospital stay six days; the feto-maternal haemorrhage incidence was one out of 10 cases, which compares favourably with other methods. No complications have yet been encountered.     

Gynaecological Illness after Sterilization

A total of 374 patients were followed up for at least 10 years after tubal ligation, and 43% required further gynaecological treatment. Major gynaecological surgery was needed by 25%. There seems a good case for the selective use of hysterectomy as a method of sterilization.     

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.     

Before and after therapeutic abortion

Surveys conducted after therapeutic abortion were used to evaluate contraceptive use, to assess early physical and emotional effects and to provide feedback to the hospital nurses on their counselling role. The follow-up rate was only 53%. Of those who cooperated 82.9% were using effective contraception three months after abortion. Subjective morbidity was greater than anticipated. The main emotional response was relief coupled with some guilt and depression in a significant minority. The occurrence and significance of the after effects of abortion should be explained in advance. Training workshops for abortion counsellors would be useful. The surgical termination of pregnancy is only a small part of a comprehensive abortion service.     

Sterilization: Canadian choices.

Significant differences in cost and safety between vasectomy and tubal ligation have been reported. For this reason the incidence of these two procedures between 1976 and 1986 was studied to obtain information upon which future policy decisions might be based. Although tubal ligation predominated in almost every province and year its rate declined by 27.6% over the study period, whereas the rate of vasectomy increased by 39.1%. When projected to 1988 the national rates for the two procedures became nearly equal; those for Quebec had become equal by 1986. Provincial differences were most marked in eastern Canada, where neighbouring provinces had the highest and the lowest rates of sterilization in the country. Given the relative economic and surgical disadvantages of tubal ligation, policymakers may wish to consider fostering an increased acceptance of vasectomy, particularly in areas where such acceptance continues to be slow.     

Laminaria augmentation of intra-amniotic PGF2α for midtrimester pregnancy termination

In our hands, intra-amniotic PGF₂α 40 mg for midtrimester pregnancy termination had a mean infusion to abortion interval of 29.4 hr. However, pretreatment of 230 patients with laminaria tents inserted 14–18 hr before PGF₂α infusion resulted in a dramatically reduced time to abortion (14.3 hr mean) with a low incidence of gastrointestinal and other side effects. Laminaria tents inserted at the same time as PGF₂α infusion in 26 patients also resulted in reduced time to abortion (18.6 hr mean). In the laminaria pretreated group, the infusion to abortion interval was indirectly related to the number of laminaria inserted and not to the nulliparous or parous state. Although we have made significant strides in shortening the abortion interval in the hospital, retained placentae and blood loss persist as problems related to the use of prostaglandin for abortion.     

Managing gynaecological emergencies with laparoscopy.

A consecutive series of 49 women (50 procedures), whose conditions were haemodynamically stable, presenting with acute lower abdominal pain, pelvic tenderness, and either a urine concentration of greater than 50 U/l beta human chorionic gonadotrophin or a pelvic mass shown by ultrasonography were treated with operative laparoscopy under video monitoring (videopelviscopy) as an alternative to laparotomy. Ectopic pregnancy, ovarian and non-ovarian cysts, pelvic adhesions, endometriosis, and fibroids were found, for which salpingotomy, salpingectomy and salpingo-oophorectomy, cystectomy, adhesiolysis, thermocoagulation, and myomectomy were carried out by laparoscopy. In one patient pelviscopy was repeated because of persistent tubal pregnancy after the fimbria was expressed. Laparotomies were carried out on three patients because treatment was not possible by laparoscopy and on a further patient two days after adhesiolysis had been attempted. These were the only serious complications. For the 46 cases (45 patients) in which operative laparoscopy was successful the mean stay in hospital was 1.9 days after operation, and this group of patients returned to normal activities and to work after an average of 2.3 and 2.6 weeks respectively. Most gynaecological emergencies that are managed by laparotomy can be treated by laparoscopy and benefit both patients and the health service.     

Laminaria augmentation of intra-amniotic PGF2 for midtrimester pregnancy termination

In our hands, intra-amniotic PGF_2^α 40 mg for midtrimester pregnancy termination had a mean infusion to abortion interval of 29.4 hr. However, pretreatment of 230 patients with laminaria tents inserted 14–18 hr before PGF_2^α infusion resulted in a dramatically reduced time to abortion (14.3 hr mean) with a low incidence of gastrointestinal and other side effects. Laminaria tents inserted at the same time as PGF_2^α infusion in 26 patients also resulted in reduced time to abortion (18.6 hr mean). In the laminaria pretreated group, the infusion to abortion interval was indirectly related to the number of laminaria inserted and not to the nulliparous or parous state. Although we have made significant strides in shortening the abortion interval in the hospital, retained placentae and blood loss persist as problems related to the use of prostaglandin for abortion.     

Prostaglandin-induced Abortion: Assessment of Operative Complications and Early Morbidity

A total of 626 patients undergoing a prostaglandin-induced abortion, the majority in the second trimester, have been analysed for complications occurring during inpatient treatment. Of the last 155 consecutive patients 143 were critically assessed six to eight weeks after abortion for morbidity occurring during their early recovery period.Blood loss of 250 ml or more occurred in 68 patients, pyrexia in 34, pelvic infection in three, and readmission in 14 of the 626 patients studied, and a transfusion was required in eight.Bleeding after abortion stopped within six weeks in all 143 of the 155 consecutive patients assessed but three required readmission for uterine curettage. Menstruation was re-established within six weeks of abortion in 106 patients.The incidence of operative morbidity was similar to that reported for first trimester abortion and better than that in most reported series of second trimester abortions.     

The decision to terminate childbearing: Differences in preoperative ambivalence between tubal ligation women and vasectomy wives

Abstract

This paper examines the degree of preoperative ambivalence expressed by 255 currently married tubal ligation patients compared to 167 wives of vasectomy patients regarding the decision to terminate childbearing and aspects of the decision‐making process which account for differences between groups. Data indicate that tubal ligation women are significantly more certain and comfortable with their decision than are vasectomy wives. In order to explain this finding, analysis focused on sociodemographic factors; time factors related to the decision; variables related to communication with spouse and others; factors internal to the individual, including interest in another child and motivation for the decision; external constraints on the decision; and couple dynamics in the decision‐making process. Results indicate that group differences in ambivalence are primarily due to the effects of strong male control over the termination decision, as perceived by the wife, and a disproportionate prevalence of this pattern among vasectomy couples. An interaction effect between male dominance and group membership was also found. Implications of study results for preoperative counseling, including likely sources of future regret, are considered.     

Effects of Maternal Status on the Movement and Mortality of Sterilized Female White-Tailed Deer

Abstract: Surgical sterilization by tubal ligation has been proposed as a technique for controlling white-tailed deer (Odocoileus virginianus) populations in urban or suburban areas where other forms of population control are impractical, but little is known about demographic rates in populations under management with surgical sterilization. We analyzed seasonal movement and mortality data collected during a 4-year study of surgical sterilization in suburban Chicago, Illinois, USA. We calculated 323 home range size estimates for 62 individual females within season and year. Non-gravid females without young exhibited home range sizes 52% larger than gravid females and females with fawns. Mortality rate was positively correlated with home range size. We suggest that the increased mortality rate observed in surgically sterilized females may be due to greater movement by non-maternal females. Population managers will need to account for potential effects of maternal status on movement and mortality when considering the use of sterilization for management of suburban populations of white-tailed deer.     

Abortion induced with methotrexate and misoprostol.

OBJECTIVE: To determine the outcome and side effects of a new drug protocol to induce abortion. DESIGN: Case series. SETTING: An urban primary care practice. PATIENTS: One hundred consecutive patients who requested elective termination of pregnancies of less than 8 weeks'' gestation. INTERVENTION: Subjects received methotrexate (50 mg/m2 body surface area, administered intramuscularly) and, 3 days afterward, misoprostol (800 micrograms, given vaginally). OUTCOME MEASURES: Number of abortions induced within 24 hours and within 10 days of misoprostol administration, number of surgical aspirations conducted because of incomplete abortion, mean amount of bleeding and pain and the number of women who, if faced with the same situation, said they would again choose a drug-induced abortion over a surgical one. RESULTS: Abortion occurred within 24 hours of misoprostol administration among 48 women and within 10 days among 69 women. In total, 89 women had an abortion without surgical aspiration. Of these women, 71 said they would choose a drug-induced abortion if faced with the choice again. CONCLUSION: Abortion induced with methotrexate and misoprostol appears to be a feasible alternative to surgical abortion and deserves further study.     

Pulmonary atresia with ventricular septal defect: a case for central venous pressure and oxygen saturation monitoring.

A 21-year-old patient with pulmonary atresia and ventricular septal defect (PA-VSD) was admitted to the hospital for tubal ligation. Invasive arterial and central venous (CVP) pressure, pulse oximetric oxygen saturation (SpO2), and (from the tip of oximetric central venous catheter) central venous oxygen saturation (ScvO2) and oxygen extraction rate (ExO2) were continuously monitored. Heart rate (range: 68-75 beat/min), mean arterial pressure (80-90 mmHg), CVP (7-10 mmHg), SpO2 (79-90 percent), ScvO2 (57-70 percent), and ExO2 (21-30 percent) remained stable during epidural anesthesia and transvaginal sterilization. Following an overnight stay (peak SpO2 92 percent; peak ScvO2 71 percent; through ExO2 21 percent), the oxygen data returned to baseline on awakening (SpO2 < 80 percent, ScvO2 < 55 percent, ExO2 > 35 percent), and the patient was discharged. In PA-VSD, a single-outlet double-ventricle anomaly, CVP reflects the preload of systemic ventricle. As the mixed venous oxygen saturation cannot be defined, ScvO2 is the best available indicator of the whole body oxygen consumption. Continuous monitoring of CVP, ScvO2 and ExO2 in the superior vena cava may provide more insight into the response to anesthesia and surgery in patients with PA-VSD.     

Surgical Procedures in Nonagenarians

During the hospital course of 225 nonagenarian patients who underwent 285 major operations—80% on the general, vascular, orthopedic and urologic services—overall morbidity was 37% and mortality 7.5%. The 100 emergency operations were associated with a higher morbidity and mortality rate. Nonsurvivors were more likely to have associated cardiac or cerebral medical conditions, higher utilization of intraoperative invasive hemodynamic monitoring and greater use of surgical intensive care units. Compared with all surgical patients, the nonagenarians were admitted twice as often to the surgical intensive care unit, required twice the number of hospital days, underwent intraoperative hemodynamic monitoring twice as frequently and incurred 200% greater hospital charges. We conclude that with careful evaluation and management, a nonagenarian patient presenting with a surgical condition can safely undergo necessary operative procedures.     

Intrauterine instillation of prostaglandin F2ALPHA IN EARLY PREGNANCY.

Intrauterine PGF2alpha (5mg) was administered for termination of early pregnancy in 14 healthy volunteers. With 11 complete abortions, the efficiency rate of this technique is below conventional methods. In addition, the incidience of infection was high occuring in 12 out of 14 subjects. Because of persistent bleeding, six patients underwent a dilatation and curettage. Other significant side effects included transient hypertension, pain, nausea and restlessness. In the patients with a complete abortion, the mean plasma progesterone concentration fell 37% after 8 hours post PGF2alpha instillation and 90iod and 75% over the next 14 days.     

Ten-minute abortions.

A service performing very early abortions in a district general hospital uses menstrual aspiration, which enables abortion to be carried out early, easily, safely, and simply. Menstrual aspiration avoids interference with routine gynaecological work and permits an operator to widen his criteria for accepting patients for termination. From September 1975 to April 1977 123 cases were referred and 104 aspirations were performed. Termination of pregnancy failed in only two cases, through inexperience, and infection occurred in only one case. Menstrual aspiration should be performed within 10-18 days of missing a period.     

Laparoscopic radical prostatectomy--analysis of our first 100 consecutive cases

The aim of this study was retrospective study of our first 100 consecutive cases of prostatic cancer, operated by laparoscopic approach and comparison with 100 cases of open retropubic radical prostatectomy (RRP) at our department, focusing on operative data and morbidity. From June 1999 to August 2003 we have performed first consecutive 100 laparoscopic radical prostatectomies (LRP), all according to Montsouris technique. In this study we have compared the results with 100 patients who underwent from May 1997 to August 2003 open RRP. Mean operative time was shorter after RRP (155 vs. 234 min, p = 0.018). Mean blood loss was significantly lower in LRP group (446 vs. 710 ml, p < 0.001). Mean catheter duration time (6.4 vs. 10 days, p < 0.001) and hospital stay (8.6 vs. 11 days, p < 0.001) were significantly shorter in LRP group. There was no statistically significant difference in complication rate in both groups (p = 0.139). Laparoscopic radical prostatectomy is a safe procedure for the patient and complications do not appear more often than in the open operation. In LRP we detected shorter mean catheter duration time, shorter hospital stay and less blood loss. This procedure demands perfect knowledge of the laparoscopic operative technique and due to long-term learning curve, the procedure could be done only in particular centers, where exist suitable equipment and also experienced operators in laparoscopic technique.     

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.