Use of osmotic dilators to facilitate induced midtrimester abortion: clinical evaluations.

A number of studies evaluating an osmotic cervical dilator consisting of polyvinyl foam saturated with magnesium sulphate in women undergoing midtrimester abortion with intra-amniotic hyperosmolar urea plus prostaglandin F2a were completed. Comparisons with women receiving no pre-treatment with a laminaria tent or with one laminaria indicate that their use appears to shorten injection-abortion intervals, particularly in parous women, and reduce risk of endometritis and cervical laceration compared to women not receiving any type of device. The data suggests that two osmotic dilators may be more effective than one. Also, magnesium toxicity does not appear to be a substantial risk with their use.

Morbidity risk among young adolescents undergoing elective abortion.

A cohort study comparing risks of morbidity at the time of elective abortion between 399 young adolescents aged 17 years or less matched to 399 women aged 20 to 29 years was completed. The study matched for duration of gestation, types of procedure, parity, race, month of procedure, and insurance status. Results indicated a relative risk of post-abortal endometritis for adolescents compared to older women of 2.5 (95% C.L. 1.48, 3.85). The reasons for this difference are unclear.

PIP: To determine whether younger teenagers (age 17 years or less) face differing morbidity than other women, a cohort study comparing risks of morbidity at the time of elective abortion between 399 young adolescents aged 17 years or less matched with 399 women aged 20-29 years was undertaken. Only women undergoing suction curettage up to 14 weeks duration of gestation or urea amnioinfusion in combination with intraamniotic prostaglandin F2alpha or intravenous oxytocin at 16-22 weeks duration of gestation were included. Cohert subjects were women who had undergone their abortion care in Fertility Control Center at Johns Hopkins Hospital (Baltimore, Maryland) between January 1, 1976 December 31, 1978. The occurence of endometritis was the only complication found more frequently among the adolescents to a significant degree. Among the endometritis patients, 7 adolescents and 2 control women were hospitalized for intravenous antibiotic therapy. The study indicates that adolescents undergoing abortion procedures are at increased risk for postabortal endometritis once other factors such as gestational age, type of abortion procedure, parity, race, level of operation traning, and socioeconomic status have been controlled. Cervical laceration has been shown previously to be about twice as common among women aged 17 years or less compared with older women. The current study demostrated a similar trend but not to a statistically significant degree. Reasons for the increased rated of postabortal endometritis are unclear. The study demonstrated increased rates of preexisting cervical gonorrhea and urinary tract infection among the adolescents compared with the older women, but all of these women underwent treatment prior to the procedure and none experienced endometritis. Careful monitoring after the procedure for the occurence of infection is of obvious importance. Whether routine use of prophylactic antibiotics in this group would be of substantial benefit may deserve further study.

Cephalothin prophylaxis for midtrimester abortion.

A randomized prospective double-blind study was conducted to determine the efficacy of prophylactic antibiotics as compared with placebo in 198 women undergoing second-trimester intraamniotic injection abortions. Patients received either sodium cephalothin or placebo intravenously before the procedure and for up to 8 additional doses. In 11 patients postabortion endometritis developed; 2 had received the antibiotic and 9 had received a placebo (P less than .05). Prophylactic cephalothin decreased the incidence of endometritis in patients undergoing midtrimester injection abortion. An injection-abortion interval greater than 24 hours appears to identify patients at risk for the development of postabortion endometritis.

The incidence of abdominal surgical procedures in a population undergoing abortion.

The incidence of abdominal surgical procedures was determined in 11,885 patients undergoing termination of pregnancy. Thirty-eight abdominal surgical procedures were completed, an incidence of 3.9 per 1,000 abortion cases. Seventy-two percent were completed for the diagnosis and management of coexistent genital pathologic conditions, with the remainder required for the management of abortion complications. These data provide patients an estimate of their chances of having to undergo abdominal surgical procedures, prior to their making a final decision to have a pregnancy terminated.

PIP: 11,885 patients who had undergone pregnancy termination procedures were studied retrospectively to provide data on the incidence of subsequent abdominal surgical intervention; it was hoped that such information would be useful to physicians in their recommendations for future abortion procedures. Of the 11,885 patients, 38 had undergone abdominal surgery after abortion. The incidence then for subsequent abdominal surgery to abortion cases was 3.9/1000 abortion cases. Of these 38 cases, 72% of the surgeries were performed for diagnosis and management of coexistent genital pathological conditions; the remainder were required for management of abortion complications. These data will help patients estimate their chances of having to undergo further surgery as a result of submitting to an abortion.

Gestational trophoblastic disease within an elective abortion population.

Gestational trophoblastic disease, most commonly hydatidiform mole, is an unusual condition within the United States. The incidence of hydatidiform mole has been reported to vary from 1 in 1,200 to 1 in 2,000 pregnancies. This report described eight cases of hydatidiform mole among 4,829 patients presenting for elective first-trimester abortion. Factors which might account for the frequency of hydatidiform mole of 1 in 600 are discussed. Although the clinical course of patients with hydatidiform mole appears benign- gross examination of tissue obtained at suction curettage and the liberal use of histologic evaluation in questionable cases is required to make the diagnosis.

PIP: The experience in the Fertility Control Center (Baltimore, Maryland) with gestational trophoblastic disease is reviewed. Over the July 1, 1973 through June 30, 1976 period, 4829 patients underwent suction curettage. About 75% had gestations of 12 weeks or less while the remaining 25% were beyond 12 weeks. All patients presenting for abortion were screened with a history, physical examination, and laboratory tests includng a urine pregnancy test. The suction curettage procedures were carried out using paracervical block anesthesia and intravenous analgesia. All obtained tissue was submitted for pathologic review. The criteria used to diagnose gestational trophoblastic disease include presence of placental villi with edema, loss of vasculature, and varying degrees of trophoblastic proliferation. 8 cases of hydatidiform mole were diagnosed during the study period. The frequency of hydatidiform mole within the group of patients presenting for suction curettage was about 1/600. Of the patients with molar pregnancy, 6 of 8 were 16 or less, 6 of 8 were black, all but 1 was single, and 5 of 8 were nulliparous. All patients with the diagnosis of hydatidiform mole developed negative titers within 6 weeks, and no patient needed chemotherapy.

Placental histopathology of midtrimester termination.

Placentas spontaneously passed after second-trimester terminations of pregnancy using either hypertonic sodium chloride or hyperosmolar urea plus prostaglandin F2alpha (PGF2alpha) were examined to determine histologic characteristics. The placentas of hypertonic sodium chloride terminations demonstrated a type of "coagulation necrosis" that has been described previously, while placentas of pregnancies terminated by hyperosmolar urea plus PGF2alpha showed a similar pattern in about one half the cases but a histologic pattern of less severe damage in the remaining cases. The 2 groups showed no significant differences when characteristics such as injection-abortion interval or estimated hypertonicity of the fluid were examined.

PIP: Second trimester placentas, passed spontaneously in 17 abortions induced by hypertonic sodium chloride and in 45 abortions induced by hyperosmolar urea plus prostaglandin F, were histologically compared; in 16 of the 17 sodium chloride cases, a pattern of severe tissue damage (Type A) was observed, and in the urea cases, approximately half of the cases exhibited Type A damage and the other half had a less severe form of damage (Type B). Type A damage is characterized by a zone of "coagulation necrosis" in which cell structure is lost, vessels are thrombosed, and there is severe inflammation. In Type B damage, cell structure is maintained, vessels are not thrombosed, and inflammation is diffuse. In previous studies of sodium chloride induced abortions, Type A damage had been noted and attributed to the hypertonicity of the abortifacient agent. Since half of the urea cases also had Type A damage, an attempt was made to discover clinical differences between the Type A and Type B urea cases. No significant differences were found; however, a scatter diagram suggests that patients with high concentrations of urea and with a longer interval between injection and subsequent abortion tended to exhibit Type A damage, while those with a shorter interval between injection and abortion manifested Type B damage. Tables include clinical characteristics of age, parity, duration of gestation, injection abortion interval, and amount of amniotic fluid removed for urea cases and a scatter diagram depicting interval time and estimated urea concentration. Photographs of tissue sections depicting Type and Type B damage are also included.

Intravascular spill of hyperosmolar urea during induced midtrimester abortion.

Intravascular spill of hypertonic sodium chloride and the resultant serious and occasionally fatal consquences have been reported in association with induced midtrimester abortion. This report details 3 cases of intravascular spill of hyperosmolar urea. Although urea may pose less concern, because of its ability to readily cross cell membranes and its action as an osmotic diuretic, inadvertent intravascular spill can produce symptoms that include nausea, headache, sensations of warmth, and intense uterine cramping. In addition, abnormal blood pigments may occasionally be noted in the urine. Treatment includes intravenous hydration, careful monitoring of fluid/electrolyte balance and renal function, and avoiding the use of oxytocic agents.

PIP: 3 cases of intravascular spill of hyperosmolar urea during induced midtrimester abortion are reported. In each case 80 gm of urea had been infused. Although urea may pose less concern than hypertonic sodium chloride because of its ability to readily cross cell membranes and its action as an osmotic diuretic, inadvertent intravascular spill can produce symptoms that include nausea, headache, sensations of warmth, and intense uterine cramping. Also, abnormal blood pigments may occasionally be noted in the urine. The 3 patients were 23, 20, and 24 years old, all para 0. The symptoms generally subsided after 30 minutes, and serum and urinary abnormalities returned to normal within 24 hours. Treatment included iv hydration, careful monitoring of fluid/electrolyte balance and renal function, and avoiding the use of oxytocic agents for at least 24 hours. The 3 patients eventually underwent successful abortions, 1 with intraamniotic prostaglandin F2 alpha (PGF2a), and 1 with urea-PGF2a abortion, without further complications.

Bacteriologic culture results obtained before and after elective midtrimester urea abortion.

Twenty patients undergoing elective midtrimester abortion by urea amnioinfusion had bacteriologic culture data obtained before and after the procedure. Despite the presence of pathogens in the vagina and cervix prior to the procedure, only 20% of patients exhibited endometrial growth following abortion. Factors that seem to favor such endometrial growth include increased injection-abortion intervals and the requirement for curettage to manage incomplete abortion.

Hyperosmolar urea for elective midtrimester abortion. Experience in 1,913 cases.

Intra-amniotic hyperosmolar urea (59.7 per cent) augmented by intravenous oxytocin (332 millimicron per minute), prostaglandin F2alpha (20 mg.), prostaglandin F2alpha (10 mg.), or prostaglandin F2alpha (5 mg.) was utilized for 1,913 patients requesting elective midtrimester abortion. Injection-abortion intervals ranging from 13.70 to 21.49 hours were achieved with failure rates of 0.7 to 6.7 per cent. Despite frequent pre-existing medical conditions, the complication rate compared favorably with those of other methods for terminating midtrimester pregnancy such as saline amnioinfusion or dilatation and evacuation.

Intra-amniotic urea and prostaglandin F2alpha for midtrimester abortion: clinical and laboratory evaluation.

The clinical management of the elective midtrimester abortion continues to be unsatisfactory as judged by either national mortality or morbidity rates. This report documents the results of a randomized series of 19 midtrimester abortions induced by either intra-amniotic hyperosmolar urea and 5 mg. of prostaglandin F2alpha (PGF2alpha) or intra-amniotic hyperosmolar urea alone. Pertinent clinical characteristics and biochemical determinations were compared between these two groups. A series of 150 patients were then treated with urea and 5 mg. of PGF2alpha. The clinical results of this series of patients are presented and compared with a previous group who had urea and 10 mg. of PGF2alpha. These studies demonstrate that 5 mg. of PGF2alpha with 80 Gm. of urea achieves injection-abortion intervals that are less than 24 hours.

PIP: Intraamniotic urea and prostaglandin F2 alpha (PGF2a) combinations for midtrimester abortion were compared in the following series: 8 multiparas given 80 gm urea in 135 ml 5% dextrose and 5 mg PGF2a, 8 multiparas given urea only, 150 nulliparas and multiparas given urea and 5 mg PGF2a, and 180 given urea and 10 mg PGF2a. In the 2 small series, there was 1 failure in the urea group. Mean abortion times were 28.8 hours after urea, 18.3 hours after urea and 5 mg PGF2a, and 16.3 and 17.5 hours in the 2 large series given urea and 10 and 5 mg PGF2a, respectively. Urea caused loss of fetal heart tones within 2 hours, had a half-life in amniotic fluid of 3 hours, caused a low frequency of late emesis, and resulted in short-lived burning or warm sensation in 1 case of accidental intravascular injection. Oxytocin infusions were used frequently for failure to abort within 24 hours, or lack of uterine contractions after membrane rupture or incomplete abortion. PGF2a accelerated uterine tone, frequency, and integrated uterine pressure over the values measured in subjects given urea only.

Culture and treatment results in endometritis following elective abortion.

Endometrial culture and treatment results from 228 patients who developed endometritis following elective abortion were analyzed. The most common organisms isolated were group B beta hemolytic streptococci, Bacteroides, Neisseria gonorrhoeae, E. coli, and Staphylococcus aureus. In general, patients responded to treatment with penicillin or ampicillin, with the addition of an aminoglycoside for these requiring hospitalization. Curettage was an important adjunctive treatment for hospitalized patients and for some outpatients.

Coagulopathy with midtrimester induced abortion: association with hyperosmolar urea administration.

Coagulation changes, usually subclinical, have been reported in association with the induction of midtrimester abortion by the administration of intra-amniotic hypertonic sodium chloride, hyperosmolar urea, hyperosmolar urea plus prostaglandin F2alpha, and hyperosmolar ura or hypertonic glucose plus prostaglandin E2. In addition, clinically significant coagulopathy has been described in association with the administration of hypertonic sodium chloride. This study details a three-year experience involving 3,034 cases of midtrimester elective abortion and describes six cases of coagulopathy in association with the administration of hypertonic sodium chloride and two cases in association with the administration of hyperosmolar urea. The significance of these findings and etiologic considerations are discussed.

The management of midtrimester abortion failures by vaginal evacuation.

The management of 58 failed midtrimester primary abortion procedures by vaginal uterine evacuation is described. The indications, technic, and complications of this procedure are presented. This method was the only means of managing failed primary abortion over a 3-year period in which 2045 elective midtrimester abortions were performed. With the development of experience this technic offers significant advantages over other procedures, such as hysterotomy, in the management of such patients.

Untreated endocervical gonorrhea and endometritis following elective abortion.

A matched-pair analysis of 228 cases of endometritis occurring over a two-year period in 4,823 elective abortion patients was carried out. Patients with postabortal endometritis were matched with control subjects for age, parity, race, pay status, time of abortion, and type of abortion procedure. The prevalence of endocervical gonorrhea was 2.7% in the entire group seeking abortion, with 14.7% of patients with gonorrhea subsequently developing endometritis. The matched-pair analysis detected a threefold increased risk for endometritis in patients with untreated gonoccocal endocervicitis when compared with control subjects (p less than 0.05). The significance of these findings to centers performing abortions is discussed.

Intra-amniotic urea and prostaglandin F2 alpha for midtrimester abortion: a modified regimen.

A study comparing intra-amniotic urea plus intravenous oxytocin and intra-amniotic urea with 10 mg. prostaglandin F2 alpha was completed. In addition, the results obtained with a further 150 patients receiving urea and prostaglandin are reported. Mean injection-abortion intervals ranged from 15.75 hours for urea-prostaglandin to 18.93 hours for urea-oxytocin. The advantages of urea-prostaglandin and suggested improvements are discussed. Over all, the method appears efficacious though incomplete abortions and cervical laceration are persistent problems.

Continuing education of obstetricians and gynecologists in fertility management.

One of the current fundamental problems in medicine is the massive quantity of new information that continues to develop and the requirement for the application of these data to good patient care. New techniques of merit need to be placed rapidly in the patient-care arena and the time lag between the steps from laboratory to clinic minimized. One approach to the achievement of the goal in fertility management is described in the following report; namely, a summary of the results of an education program in fertility management established in November, 1972, for the continued education of obstetricians and gynecologists from "developing countries". This report reviews the experience and data derived from the first 95 physicians completing a course in population dynamics. An estimate of the factual knowledge that these individual physicians possessed at the beginning of the course is compared with an estimate of the knowledge acquired within the 4 week training program. In a similar manner, an important part of this survey was a study of the attitudes of the clinical fellows in the areas of sex education, contraception, sterilization, and abortion. The results of this study suggest that newly developed techniques in clinical medicine may be taught to a specific and highly motivated group in an effective and efficient manner. The initial interest and response of physicians for admission to this program have demonstrated the need for the development of more similar educational programs.

Menstrual extraction.

This report documents the clinical outcome of 137 consecutive menstrual extractions. The pre- and postprocedural pregnancy testing is correlated with histologic examination of tissue obtained. This report reviews the management of the unsuccessful cases.