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Abortions by resident physicians in a municipal hospital center
Abortions by resident physicians in a municipal hospital center J.
JOSHUA
KOPELMAN,
GORDON New
York,
W. New
M.D.*
DOUGLAS,
M.D.
York
In Bellevue Hospital, a municipal hospital serving a densely populated area, the majority of abortions are performed by the junior resident staff, under the supervision of attending physicians. Abortion statistics, birth statistics, and a review of significant complications of in-hospital abortions for the period of July 1, 1970, through February 28, 1971, are presented, and comparisons are made with related data for the same period in 1968. Our figures indicate that even in relatively inexperienced hands in-hospital abortions on a large scale can be performed with a low incidence of complications. Most of the immediate complications, however, are potentially life-threatemng and require prompt, experienced gynecologic management in a hospital setting.
0 N J u L Y 1, 1970, New York became the first of the densely populated states to allow nearly unlimited access to abortion as a method of dealing with an unwanted pregnancy. This placed a markedly increased workload on the professional staffs of the municipal hospitals, with little or no compensatory increase in the numbers of trained personnel to handle the increased number of patients. At some municipal hospitals, the task of performing abortions has been delegated to the junior residents of the obstetric and gynecologic services. At Bellevue Hospital, these physicians are trained and closely supervised by the attending staff of the Department of Obstetrics and Gynecology. One pursuasive argument for the liberalization of abortion laws has been that terminations of pregnancy by experienced physicians in appropriate, medically approved facilities would reduce or eliminate the supposedly high incidence of morbidity accompanying illegal abortion1 Our statis-
tics indicate that with proper supervision and training physicians with no prior experience in terminations of pregnancy can quickly become safe and proficient practitioners of this aspect of gynecologic practice. Accurate statistics concerning hospital admissions for the complications of illegally induced abortions are difficult to obtain. It was felt that the change in New York’s abortion law might provide an opportunity to examine this question in the light of our early experience. It was our impression that a significant drop in the numbers of curettages for incomplete abortion after July 1> 1970, would indicate that fewer dangerous, illegal abortions were being performed. We also wished to extrapolate our findings in order to determine, if possible, the spontaneous and illegal abortion rate in our clinic population prior to passage of the new law. For reasons which will be discussed later, our data do not allow us to do more than speculate concerning our spontaneous and illegal abortion rates prior to July 1, 1970. However, the authors feel that the data presented have significance to those who are now, or may soon be, involved in providing abortion services to large clinic populations.
From the Department of Obstetrics and Gynecology, New York University School of Medicine, and the Obstetrical and Gynecological Service, Bellevue Hospital. *Present Denver,
address: Colorado
303 Josephine 80206.
St., 666
Volume Number
Abortions
111 5
It is of particular relevance to those involved in resident teaching programs since nearly all of the increased workload at Bellevue Hospital was handled by the same number of obstetric and gynecologic residents as were enrolled in the teaching program in 1968. Materials
and
methods
Operating room records and pathology reports for all curettages performed at Bellevue Hospital from July 1, 1968, to February 28, 1969, and July 1, 1970, to February 28, 1971, were reviewed. A review of the delivery room records for the same periods was also performed. Postpartum and postoperative diagnoses were categorized as “obstetric deliveries,” “voluntary interruptions of pregnancy, ” “incomplete abortions,” and “curettages” for all other causes. Up to the end of the twelfth week of pregnancy, abortions were performed by curettage. Dilatation was accomplished with graduated half-size Hegar dilators, and suction curettage was performed with the use of an Air Shields Vacurette; 10, 12, and 14 mm. disposable curettes were employed. Patients with pregnancies of 9 weeks’ duration or less were evaluated in the outpatient clinic, admitted by appointment directly to the operating room, and aborted under a brief general anesthesia. After an appropriate period of postoperative observation, usually 4 to 6 hours, they were discharged in the company of an escort. Those beyond 9 weeks’ gestation, as well as patients having medical complications, were admitted and evaluated in the hospital. Patients requesting abortion beyond the thirteenth week of pregnancy were scheduled for admission after the sixteenth week and were aborted by saline instillation. Our technique, similar to that described by Reiss,2 involves sterile aspiration of 200 C.C. of amniotic fluid from the uterine cavity via a plastic catheter introduced with the use of a percutaneous trochar passed under local anesthesia. A solution of 20 per cent saline, 200 c.c., is then dripped slowly into the gestational sac over 30 to 60 minutes.
by resident
physicians
667
Table I. Obstetric
deliveries and voluntary of pregnancy at Bellevue
interruptions Hospital
Obstetric
deliveries
Curettage interruption pregnancy
for
781
of
Saline instillations interruption of pmznancy Total voluntary interruptions pregnancy
777
11
925
- 0
401
11
1,326
for
of
The patient remains in the hospital until the abortion is complete. Inpatients aborted by either curettage or saline instillation were required to remain in the hospital for at least 12 hours following termination of their pregnancies. Results Table I reveals that 11 therapeutic abortions were performed at Bellevue Hospital between July 1, 1968, and February 28, 1969, while 1,326 were performed during the same period in 1970 to 1971. All but 153 of these were performed by the junior house staff on obstetrics and gynecology, under attending supervision. Births during the study period in 1968 to 1969 totaled 777, a difference of only 4 from the 8 month period of 1970 to 1971 which totaled 781. Table II compares the number of dilatation and curettage procedures for all reasons during the 1968 to 1969 and 1970 to 1971 study periods. Again, it should be emphasized that nearly 925 curettages for abortion, all involving an admission history and physical examination by the house staff, were performed during regular operating hours, by the house staff, as compared with 347 curettages for all reasons during the same period in 1968 to 1969. It is apparent that abortions accounted for nearly 75 per cent of the junior residents’ curettage experience during the 1970 to 1971 study period.
668
Kopelman
and
Douglas
Table II. Curettages
performed
at Bellevue
Hospital
/
July I, 1968 to Feb. 28, 1969
I Curettage for interruption of pregnancy Curettage for incomplete abortion Curettage for all other reasons Total curettages *One
hundred
Table III.
fifty-three
Corrected*
of 925 were
performed
July 1, /1970 to Feb.
28, I I
1971
Nq.
%
11 18‘l
3 33
92.5”
74.5
1 :?I6
II
l-ii’
44
180
347
100
by attrnding
rates of curettage
I I I
NO.
14.5
I.241
100
physicians.
at Bellevue
Hospital
July 1, 1968 to Feb. 28, 1969
___-
‘jr,
July 1, 1970 to Feb. 28, 1971
__
No.
70
No.
7c
Total curettages less voluntary interruptions of pregnancy
336
100
316
100
Curettage for incomplete
184
55
136
45
abortion
Curettage for all other reasons *Corrected
by subtracting
curettages
152 for
interruption
4.5
of pregnancy
Table III is a comparison of the frequency of curettages performed for other than voluntary abortions during the 2 study periods. The total of non-pregnancy-termination curettages for the 2 study periods were similar: 336 in 1968 to 1969 and 316 in 1970 to 1971. The “corrected” frequency of curettage for incomplete abortion was calculated after subtracting voluntary interruptions of pregnancy (VIP) from total curettages. Although the incomplete abortion rates show only a small drop from 1968 and 1969 to 1970 and 1971, these figures are statistically significant at the 95 per cent confidence level3 Table IV lists the 13 major complications encountered and the emergency treatment provided for the 478 patients aborted by curettage during the 1970 study period. No major complications were encountered during the performance of 11 therapeutic abortions during the 1968 to 1969 study period. All perforations as well as blood loss requiring immediate transfusion were considered major complications of curettage. There were no fatalities associated with abortion by curettage at Bellevue Hospital. As a basis of comparison during the period of review for this study, only one complication, a perforation of the uterus in a
from
total
180 curettages
(Table
.57 I).
65-year-old patient, occurred among 652 curettages not associated with voluntary abortion. Table V lists the complications which occurred in 47 of 401 patients aborted by saline instillation during the 1970 and 1971 study period. As will be noted, 2 live-born fetuses are listed. These occurred early in our experience, when we accepted patients up to the twenty-fourth week of pregnancy for abortion. Since that time, our policy has changed, and we no longer induce abortion after the end of the twenty-first week, except for therapeutic reasons. In all cases reported in Table V, treatment for retained placenta was dilatation and curettage and treatment for fever was by appropriate antibiotic therapy. In our patients, no evidence of endotoxic shock was found. However, 3 patients had documented thrombocytopenia which may be an indication of endotoxemia.4 Comment It has been widely reported that the rate of spontaneous abortion after the fourth week of gestation is approximately 10 per cent of a11 pregnancies.5 However, some authors, basing their figures on recovery of po-
Volume Number
Abortions
111 5
Table IV. Major pregnancy
complications at Bellevue Hospital Week of gestation
Date 7/8/70
8/l 3/70
g/8/70
Age
and treatment
of 936 curettages
Pa Gty
by resident
physicians
for interruption
of
Treatment
Complication
8
29
2-o-0-2
Perforation of uterus, of sigmoid serosa
10
20
o-o-o-o
Dilatation canal
6
34
5-o-1-5
Perforation laceration
of uterus, of small
of false
tear
cervical
g/28/70
12
19
o-o-o-o
Perforation
of uterus
10/16/70
10
26
4-o-o-4
Perforation
of uterus,
bowel
Laparotomy uterine sigmoid
for repair of perforation and serosal tear
Repair of cervical laceration from below, completion of curettage Hysterotomy and bowel resection
shock
Abdominal
10
21
3-o-o-3
Perforation of uterus and broad ligament, hypotension
10/20/70
10
40
6-O-l-6
Perforation tension
of uterus,
Hysterotomy, uterine ligation
10/24/70
8
18
1-0-O-l
Perforation
of uterus
12/7/70*
8
26
5-O-2-5
Laceration
l/11/71
8
20
1-o-1-1
Perforation
l/18/71*
10
39
5-o-o-5
l/21/71
12
22
8
25
*Cases
included
in statistical
compilations
hypo-
of
hysterectomy
10/17/70
1
small
Hysterotomy, repair uterine wall
Hysterotomy, uterus and ment tear
Z/2/7
669
repair broad
of liga-
repair laceration,
of tubal
Repair from
of uterine above
Repair
of rectal
Packing tion;
of uterus, observano laparotomy done
Perforation of bowel during postabortion abdominal tubal ligation
Repair
of bowel
o-o-o-o
Failure to complete tion by curettage, tension
Hysterotomy
4-o-1-4
Perforation
although
of rectum during vaginal tubal ligation following VIP
the
tentially blighted ova prior to the onset of menstruation, report up to 50 per cent of all conceptions may end in spontaneous abortionE Past experience at Bellevue Hospital has shown that nearly all patients with incomplete abortion who claim to have “fallen down the stairs,” or “. . . in the bathtub,” and who show no evidence of external trauundergone induced abortions. ma, have Moreover, it was felt that patients presenting with febrile incomplete abortions probably had also undergone induced abortion
curettages
of uterus
aborhypo-
of uterus
in each
case were
laceration laceration
laceration
required
Repair of perforation above, abdominal ligation
from tubal
uncomplicated.
by mechanical interference with the pregnancy. If these rules of thumb were reasonably accurate, approximately 60 per cent of all incomplete abortions undergoing dilatation and curettage at Bellevue Hospital were believed to be the result of illegal interruptions of pregnancy. As noted in Tables II and III, a small but significant drop in the numbers of incomplete abortions was noted for the 8 month period ending February 28, 1971. Although it would be satisfying to attribute this drop
670
Kopelman
and
Douglas
Table V. Complications 401 patients undergoing
occurring in 47 of saline instillation / No.
Retained
placenta,
afebrile
Retained
placenta,
febrile
‘9
1 5% 7.25
.i
1.23
8
2.0
Excessive blood loss, requiring transfusion as well as curettage*
1
0.2.5
Living
2
0.50
1
0.25
Fever
alone
aborted
fetust
Hysterotomy required after repeated failed saline and pitotin induction, age 35, multipara Suction failed
curettage required saline inductionS
after 1 4t
*Twin tBoth primipara.
gestation,
age
were 24 week age 20.
SMultiple contractions,
l&myomas primipara,
44,
grand
gestations,
age
prevented 16.
0.25 11.7.’ -
multipara. multipara, adequate
age 32,
and
expulsive
to a decrease in the number of unskilled criminal abortions being performed in New York City, this assumption cannot be made. It must be noted that early voluntary abortion reduces the number of “curettages for incomplete abortion” by excluding all patients who might otherwise have aborted spontaneously at a later date. For this reason. and because no statistics on actual numbers of illegal abortions will ever be obtained, no valid conclusions can be drawn from a comparison of curettages for incomplete abortion during the pre- and post-abortion-on-demand era in New York State. The rise in the numbers of “curettages for all other reasons” between the 2 periods under study is also not readily explained. It may reflect an increased utilization of our hospital’s outpatient facilities between 1968 and 1971, brought about by the exclusion of large numbers of low-income, but not welfare, families from the State’s Medicaid roles. Thus, patients who had been receiving private medical and gynecologic care at nearby voluntary hospitals during 1968 to
It is e\Gdent that since the nurnbcr of &liveries and the number of nonvoluntar) abortion curettages do not differ apprrciably cluring the 1968 and 1970 study ptrriods, the 1,326 voluntary interruptions of pregnancy represent an excess case load. It is our belirf that the Rellevue Abortion Clinic is successfully caring for all of the usual Bellevue population requesting abortion, plus a very large number of patients from “outside” our geographic district. Whatever the sauce of our abortion patients, it is significant that. despite the markedly increased work load which has fallen upon the junior house staff, our voluntary abortion service has adequately and safely discharged its responsibilities. Moreover. there has btcn no diminution of the volume or quality of clinical and surgical material treated by the Bellevue house staff, junior OI senior, during the first 8 months of the 1970 to 197 1 academic year. Because abortions at Uellevue Hospital are carried out primarily by junior house staff under attending supervision, our low incidence of serious, iulmediate complications is significant. Reference to Table I\’ indicates that the complication rate, attendant on 925 curettages for abortion, is only 1.4 per cent. Thp complication rate following curettage is I)articularly remarkable in v&v of the fact that all but 153 of the 925 curettages for abortion were performed by junior gynecology residents and junior general surgery residents who were rotating for the first time through a gynecology service and had no prior experience \vith interruption of pregnancy. This complication rate is, however, 10 times the complication rate for nonabortion curettages during the periods under study. There \vcre no deaths associated with the 12 perforations noted during curettage. However, the’ patient who underwent hysterectomy and 3 of the 8 other patients requiring laparotomy suffered severe hypoten-
Abortions
Volume 111 Number 5
sion and blood loss, requiring transfusion of 2 or more units of blood. In each case, the patients underwent laparotomy in the operating room where the curettage was performed and would probably not have survived transfer to a distant surgical facility. In no case was a serious complication undiagnosed at the time of curettage, and no patients were known to have had severe complications after having left the hospital. However, our follow-up on the abortion patients is not uniform, so that we are not in a position to learn of every late postabortal complication. Table V reveals that a markedly higher complication rate is associated with saline instillations than with curettages for abortion at Bellevue Hospital. This cannot be construed as a result of the procedure being performed by junior residents, as a 15 per cent complication rate was found among New York University Hospital patients7 where attending physicians perform the instillations. Our 11.7 per cent complication rate for saline abortions appears to be primarily the result of incomplete placental separation in patients aborted between 16 and 18 weeks of pregnancy. Age and parity of the patient undergoing saline instillation for abortion do not seem to be factors correlating with complications encountered in our series. This is in contrast to our experience with perforations during curettage for abortion,
by resident
physicians
671
where the older patient of higher parity appears to be at greater risk. Periodic reviews of our abortion techniques and complications have allowed US to refine our procedures in order to reduce operative morbidity. For example, it is now our clinical impression that a “hands-off” policy with regard to manual removal of the placenta earlier than 6 hours post delivery has reduced the number of curettages performed for retained placental fragments. Of course, the patient must be carefully observed for signs of serious hemorrhage while awaiting delivery of the placenta, but this has not occurred in our experience. Obviously, the complication of a live abortus can be best avoided by early abortion. As stated above, we no longer accept patients for voluntary nontherapeutic abortion later than the twenty-first week of gestation. As more data from our own and various other centers become available, the effects of a relatively unrestricted abortion law upon the health and birth rate of our reproductive population will become more apparent. At the present time, we feel that the procedures described above can be carried out with reasonable safety by junior house staff, in a hospital setting, as long as appropriate supervision is provided and due regard is given to the potential hazards of these operations.
REFERENCES
Man,
F.
A.
K.:
Proc.
Roy.
Sot.
Med.
62:
62:
832,
827, 1969. R&s, H. 1969: Mainland, 116: 591. Cohen, P., Med. 117:
E.:
Proc.
Roy.
Sot.
D., and Murray, I. 1952. and Gardner, F. H.: 113, 1966.
Med. M.:
Science
Arch
Intern.
Jeffcoate, T. N. A.: Principles of Gynecology, ed. 3, New York, 1967, Appleton-CenturyCrofts, Inc. Hertig, A. T., and Rock, J.: AM. J. OBSTET. GYNECOL. 58: 968, 1949. Zinberg, S.: Unpublished statistics.
JOSHUA
KOPELMAN,
GORDON New
York,
W. New
M.D.*
DOUGLAS,
M.D.
York
In Bellevue Hospital, a municipal hospital serving a densely populated area, the majority of abortions are performed by the junior resident staff, under the supervision of attending physicians. Abortion statistics, birth statistics, and a review of significant complications of in-hospital abortions for the period of July 1, 1970, through February 28, 1971, are presented, and comparisons are made with related data for the same period in 1968. Our figures indicate that even in relatively inexperienced hands in-hospital abortions on a large scale can be performed with a low incidence of complications. Most of the immediate complications, however, are potentially life-threatemng and require prompt, experienced gynecologic management in a hospital setting.
0 N J u L Y 1, 1970, New York became the first of the densely populated states to allow nearly unlimited access to abortion as a method of dealing with an unwanted pregnancy. This placed a markedly increased workload on the professional staffs of the municipal hospitals, with little or no compensatory increase in the numbers of trained personnel to handle the increased number of patients. At some municipal hospitals, the task of performing abortions has been delegated to the junior residents of the obstetric and gynecologic services. At Bellevue Hospital, these physicians are trained and closely supervised by the attending staff of the Department of Obstetrics and Gynecology. One pursuasive argument for the liberalization of abortion laws has been that terminations of pregnancy by experienced physicians in appropriate, medically approved facilities would reduce or eliminate the supposedly high incidence of morbidity accompanying illegal abortion1 Our statis-
tics indicate that with proper supervision and training physicians with no prior experience in terminations of pregnancy can quickly become safe and proficient practitioners of this aspect of gynecologic practice. Accurate statistics concerning hospital admissions for the complications of illegally induced abortions are difficult to obtain. It was felt that the change in New York’s abortion law might provide an opportunity to examine this question in the light of our early experience. It was our impression that a significant drop in the numbers of curettages for incomplete abortion after July 1> 1970, would indicate that fewer dangerous, illegal abortions were being performed. We also wished to extrapolate our findings in order to determine, if possible, the spontaneous and illegal abortion rate in our clinic population prior to passage of the new law. For reasons which will be discussed later, our data do not allow us to do more than speculate concerning our spontaneous and illegal abortion rates prior to July 1, 1970. However, the authors feel that the data presented have significance to those who are now, or may soon be, involved in providing abortion services to large clinic populations.
From the Department of Obstetrics and Gynecology, New York University School of Medicine, and the Obstetrical and Gynecological Service, Bellevue Hospital. *Present Denver,
address: Colorado
303 Josephine 80206.
St., 666
Volume Number
Abortions
111 5
It is of particular relevance to those involved in resident teaching programs since nearly all of the increased workload at Bellevue Hospital was handled by the same number of obstetric and gynecologic residents as were enrolled in the teaching program in 1968. Materials
and
methods
Operating room records and pathology reports for all curettages performed at Bellevue Hospital from July 1, 1968, to February 28, 1969, and July 1, 1970, to February 28, 1971, were reviewed. A review of the delivery room records for the same periods was also performed. Postpartum and postoperative diagnoses were categorized as “obstetric deliveries,” “voluntary interruptions of pregnancy, ” “incomplete abortions,” and “curettages” for all other causes. Up to the end of the twelfth week of pregnancy, abortions were performed by curettage. Dilatation was accomplished with graduated half-size Hegar dilators, and suction curettage was performed with the use of an Air Shields Vacurette; 10, 12, and 14 mm. disposable curettes were employed. Patients with pregnancies of 9 weeks’ duration or less were evaluated in the outpatient clinic, admitted by appointment directly to the operating room, and aborted under a brief general anesthesia. After an appropriate period of postoperative observation, usually 4 to 6 hours, they were discharged in the company of an escort. Those beyond 9 weeks’ gestation, as well as patients having medical complications, were admitted and evaluated in the hospital. Patients requesting abortion beyond the thirteenth week of pregnancy were scheduled for admission after the sixteenth week and were aborted by saline instillation. Our technique, similar to that described by Reiss,2 involves sterile aspiration of 200 C.C. of amniotic fluid from the uterine cavity via a plastic catheter introduced with the use of a percutaneous trochar passed under local anesthesia. A solution of 20 per cent saline, 200 c.c., is then dripped slowly into the gestational sac over 30 to 60 minutes.
by resident
physicians
667
Table I. Obstetric
deliveries and voluntary of pregnancy at Bellevue
interruptions Hospital
Obstetric
deliveries
Curettage interruption pregnancy
for
781
of
Saline instillations interruption of pmznancy Total voluntary interruptions pregnancy
777
11
925
- 0
401
11
1,326
for
of
The patient remains in the hospital until the abortion is complete. Inpatients aborted by either curettage or saline instillation were required to remain in the hospital for at least 12 hours following termination of their pregnancies. Results Table I reveals that 11 therapeutic abortions were performed at Bellevue Hospital between July 1, 1968, and February 28, 1969, while 1,326 were performed during the same period in 1970 to 1971. All but 153 of these were performed by the junior house staff on obstetrics and gynecology, under attending supervision. Births during the study period in 1968 to 1969 totaled 777, a difference of only 4 from the 8 month period of 1970 to 1971 which totaled 781. Table II compares the number of dilatation and curettage procedures for all reasons during the 1968 to 1969 and 1970 to 1971 study periods. Again, it should be emphasized that nearly 925 curettages for abortion, all involving an admission history and physical examination by the house staff, were performed during regular operating hours, by the house staff, as compared with 347 curettages for all reasons during the same period in 1968 to 1969. It is apparent that abortions accounted for nearly 75 per cent of the junior residents’ curettage experience during the 1970 to 1971 study period.
668
Kopelman
and
Douglas
Table II. Curettages
performed
at Bellevue
Hospital
/
July I, 1968 to Feb. 28, 1969
I Curettage for interruption of pregnancy Curettage for incomplete abortion Curettage for all other reasons Total curettages *One
hundred
Table III.
fifty-three
Corrected*
of 925 were
performed
July 1, /1970 to Feb.
28, I I
1971
Nq.
%
11 18‘l
3 33
92.5”
74.5
1 :?I6
II
l-ii’
44
180
347
100
by attrnding
rates of curettage
I I I
NO.
14.5
I.241
100
physicians.
at Bellevue
Hospital
July 1, 1968 to Feb. 28, 1969
___-
‘jr,
July 1, 1970 to Feb. 28, 1971
__
No.
70
No.
7c
Total curettages less voluntary interruptions of pregnancy
336
100
316
100
Curettage for incomplete
184
55
136
45
abortion
Curettage for all other reasons *Corrected
by subtracting
curettages
152 for
interruption
4.5
of pregnancy
Table III is a comparison of the frequency of curettages performed for other than voluntary abortions during the 2 study periods. The total of non-pregnancy-termination curettages for the 2 study periods were similar: 336 in 1968 to 1969 and 316 in 1970 to 1971. The “corrected” frequency of curettage for incomplete abortion was calculated after subtracting voluntary interruptions of pregnancy (VIP) from total curettages. Although the incomplete abortion rates show only a small drop from 1968 and 1969 to 1970 and 1971, these figures are statistically significant at the 95 per cent confidence level3 Table IV lists the 13 major complications encountered and the emergency treatment provided for the 478 patients aborted by curettage during the 1970 study period. No major complications were encountered during the performance of 11 therapeutic abortions during the 1968 to 1969 study period. All perforations as well as blood loss requiring immediate transfusion were considered major complications of curettage. There were no fatalities associated with abortion by curettage at Bellevue Hospital. As a basis of comparison during the period of review for this study, only one complication, a perforation of the uterus in a
from
total
180 curettages
(Table
.57 I).
65-year-old patient, occurred among 652 curettages not associated with voluntary abortion. Table V lists the complications which occurred in 47 of 401 patients aborted by saline instillation during the 1970 and 1971 study period. As will be noted, 2 live-born fetuses are listed. These occurred early in our experience, when we accepted patients up to the twenty-fourth week of pregnancy for abortion. Since that time, our policy has changed, and we no longer induce abortion after the end of the twenty-first week, except for therapeutic reasons. In all cases reported in Table V, treatment for retained placenta was dilatation and curettage and treatment for fever was by appropriate antibiotic therapy. In our patients, no evidence of endotoxic shock was found. However, 3 patients had documented thrombocytopenia which may be an indication of endotoxemia.4 Comment It has been widely reported that the rate of spontaneous abortion after the fourth week of gestation is approximately 10 per cent of a11 pregnancies.5 However, some authors, basing their figures on recovery of po-
Volume Number
Abortions
111 5
Table IV. Major pregnancy
complications at Bellevue Hospital Week of gestation
Date 7/8/70
8/l 3/70
g/8/70
Age
and treatment
of 936 curettages
Pa Gty
by resident
physicians
for interruption
of
Treatment
Complication
8
29
2-o-0-2
Perforation of uterus, of sigmoid serosa
10
20
o-o-o-o
Dilatation canal
6
34
5-o-1-5
Perforation laceration
of uterus, of small
of false
tear
cervical
g/28/70
12
19
o-o-o-o
Perforation
of uterus
10/16/70
10
26
4-o-o-4
Perforation
of uterus,
bowel
Laparotomy uterine sigmoid
for repair of perforation and serosal tear
Repair of cervical laceration from below, completion of curettage Hysterotomy and bowel resection
shock
Abdominal
10
21
3-o-o-3
Perforation of uterus and broad ligament, hypotension
10/20/70
10
40
6-O-l-6
Perforation tension
of uterus,
Hysterotomy, uterine ligation
10/24/70
8
18
1-0-O-l
Perforation
of uterus
12/7/70*
8
26
5-O-2-5
Laceration
l/11/71
8
20
1-o-1-1
Perforation
l/18/71*
10
39
5-o-o-5
l/21/71
12
22
8
25
*Cases
included
in statistical
compilations
hypo-
of
hysterectomy
10/17/70
1
small
Hysterotomy, repair uterine wall
Hysterotomy, uterus and ment tear
Z/2/7
669
repair broad
of liga-
repair laceration,
of tubal
Repair from
of uterine above
Repair
of rectal
Packing tion;
of uterus, observano laparotomy done
Perforation of bowel during postabortion abdominal tubal ligation
Repair
of bowel
o-o-o-o
Failure to complete tion by curettage, tension
Hysterotomy
4-o-1-4
Perforation
although
of rectum during vaginal tubal ligation following VIP
the
tentially blighted ova prior to the onset of menstruation, report up to 50 per cent of all conceptions may end in spontaneous abortionE Past experience at Bellevue Hospital has shown that nearly all patients with incomplete abortion who claim to have “fallen down the stairs,” or “. . . in the bathtub,” and who show no evidence of external trauundergone induced abortions. ma, have Moreover, it was felt that patients presenting with febrile incomplete abortions probably had also undergone induced abortion
curettages
of uterus
aborhypo-
of uterus
in each
case were
laceration laceration
laceration
required
Repair of perforation above, abdominal ligation
from tubal
uncomplicated.
by mechanical interference with the pregnancy. If these rules of thumb were reasonably accurate, approximately 60 per cent of all incomplete abortions undergoing dilatation and curettage at Bellevue Hospital were believed to be the result of illegal interruptions of pregnancy. As noted in Tables II and III, a small but significant drop in the numbers of incomplete abortions was noted for the 8 month period ending February 28, 1971. Although it would be satisfying to attribute this drop
670
Kopelman
and
Douglas
Table V. Complications 401 patients undergoing
occurring in 47 of saline instillation / No.
Retained
placenta,
afebrile
Retained
placenta,
febrile
‘9
1 5% 7.25
.i
1.23
8
2.0
Excessive blood loss, requiring transfusion as well as curettage*
1
0.2.5
Living
2
0.50
1
0.25
Fever
alone
aborted
fetust
Hysterotomy required after repeated failed saline and pitotin induction, age 35, multipara Suction failed
curettage required saline inductionS
after 1 4t
*Twin tBoth primipara.
gestation,
age
were 24 week age 20.
SMultiple contractions,
l&myomas primipara,
44,
grand
gestations,
age
prevented 16.
0.25 11.7.’ -
multipara. multipara, adequate
age 32,
and
expulsive
to a decrease in the number of unskilled criminal abortions being performed in New York City, this assumption cannot be made. It must be noted that early voluntary abortion reduces the number of “curettages for incomplete abortion” by excluding all patients who might otherwise have aborted spontaneously at a later date. For this reason. and because no statistics on actual numbers of illegal abortions will ever be obtained, no valid conclusions can be drawn from a comparison of curettages for incomplete abortion during the pre- and post-abortion-on-demand era in New York State. The rise in the numbers of “curettages for all other reasons” between the 2 periods under study is also not readily explained. It may reflect an increased utilization of our hospital’s outpatient facilities between 1968 and 1971, brought about by the exclusion of large numbers of low-income, but not welfare, families from the State’s Medicaid roles. Thus, patients who had been receiving private medical and gynecologic care at nearby voluntary hospitals during 1968 to
It is e\Gdent that since the nurnbcr of &liveries and the number of nonvoluntar) abortion curettages do not differ apprrciably cluring the 1968 and 1970 study ptrriods, the 1,326 voluntary interruptions of pregnancy represent an excess case load. It is our belirf that the Rellevue Abortion Clinic is successfully caring for all of the usual Bellevue population requesting abortion, plus a very large number of patients from “outside” our geographic district. Whatever the sauce of our abortion patients, it is significant that. despite the markedly increased work load which has fallen upon the junior house staff, our voluntary abortion service has adequately and safely discharged its responsibilities. Moreover. there has btcn no diminution of the volume or quality of clinical and surgical material treated by the Bellevue house staff, junior OI senior, during the first 8 months of the 1970 to 197 1 academic year. Because abortions at Uellevue Hospital are carried out primarily by junior house staff under attending supervision, our low incidence of serious, iulmediate complications is significant. Reference to Table I\’ indicates that the complication rate, attendant on 925 curettages for abortion, is only 1.4 per cent. Thp complication rate following curettage is I)articularly remarkable in v&v of the fact that all but 153 of the 925 curettages for abortion were performed by junior gynecology residents and junior general surgery residents who were rotating for the first time through a gynecology service and had no prior experience \vith interruption of pregnancy. This complication rate is, however, 10 times the complication rate for nonabortion curettages during the periods under study. There \vcre no deaths associated with the 12 perforations noted during curettage. However, the’ patient who underwent hysterectomy and 3 of the 8 other patients requiring laparotomy suffered severe hypoten-
Abortions
Volume 111 Number 5
sion and blood loss, requiring transfusion of 2 or more units of blood. In each case, the patients underwent laparotomy in the operating room where the curettage was performed and would probably not have survived transfer to a distant surgical facility. In no case was a serious complication undiagnosed at the time of curettage, and no patients were known to have had severe complications after having left the hospital. However, our follow-up on the abortion patients is not uniform, so that we are not in a position to learn of every late postabortal complication. Table V reveals that a markedly higher complication rate is associated with saline instillations than with curettages for abortion at Bellevue Hospital. This cannot be construed as a result of the procedure being performed by junior residents, as a 15 per cent complication rate was found among New York University Hospital patients7 where attending physicians perform the instillations. Our 11.7 per cent complication rate for saline abortions appears to be primarily the result of incomplete placental separation in patients aborted between 16 and 18 weeks of pregnancy. Age and parity of the patient undergoing saline instillation for abortion do not seem to be factors correlating with complications encountered in our series. This is in contrast to our experience with perforations during curettage for abortion,
by resident
physicians
671
where the older patient of higher parity appears to be at greater risk. Periodic reviews of our abortion techniques and complications have allowed US to refine our procedures in order to reduce operative morbidity. For example, it is now our clinical impression that a “hands-off” policy with regard to manual removal of the placenta earlier than 6 hours post delivery has reduced the number of curettages performed for retained placental fragments. Of course, the patient must be carefully observed for signs of serious hemorrhage while awaiting delivery of the placenta, but this has not occurred in our experience. Obviously, the complication of a live abortus can be best avoided by early abortion. As stated above, we no longer accept patients for voluntary nontherapeutic abortion later than the twenty-first week of gestation. As more data from our own and various other centers become available, the effects of a relatively unrestricted abortion law upon the health and birth rate of our reproductive population will become more apparent. At the present time, we feel that the procedures described above can be carried out with reasonable safety by junior house staff, in a hospital setting, as long as appropriate supervision is provided and due regard is given to the potential hazards of these operations.
REFERENCES
Man,
F.
A.
K.:
Proc.
Roy.
Sot.
Med.
62:
62:
832,
827, 1969. R&s, H. 1969: Mainland, 116: 591. Cohen, P., Med. 117:
E.:
Proc.
Roy.
Sot.
D., and Murray, I. 1952. and Gardner, F. H.: 113, 1966.
Med. M.:
Science
Arch
Intern.
Jeffcoate, T. N. A.: Principles of Gynecology, ed. 3, New York, 1967, Appleton-CenturyCrofts, Inc. Hertig, A. T., and Rock, J.: AM. J. OBSTET. GYNECOL. 58: 968, 1949. Zinberg, S.: Unpublished statistics.