Management of abortion at the Cook County Hospital

MANAGEMENT

OF ABORTION AUGUSTA

(From

the DepaWnent and

AT THE

WEBSTER, M.D.,

COOK

COUNTY

HOSPITAL

CHICAGO, ILL.

of Obstetrics, Cook: County Hospital, Gynecology, Nwrthuestern University

and the Department Medical School)

of Obstetrics

T

HE term abortion as used here is the interruption of pregnancy before the twentieth week. In the city of Chicago, a pregnancy which terminates at the twentieth week of gestation is reportable as a birth, and the hospital records so record it. Since 1939 when Hillis’ presented his statistics, new drugs and the liberal use of whole blood have altered the method of treatment. It is our intention, in so far as is practicable, to compare this review of abortions treated at the Cook County Hospital in the year 1949 with the previous report made ten years earlier. The management of abortions as outlined by Dr. Hillis was one of extreme conservatism and, indeed, it was the only safe procedure before the advent of the antibiotics. Quinine and Pituitrin in small divided doses were given to aid in evacuation of the uterus and no immediate interference was undertaken except in acute hemorrhage. If, after five days of normal temperature, the uterus had not emptied completely, a dilatation and curettage were done. At the present time, a careful pelvic examination, including speculum examination of the cervix under aseptic conditions, is made on all patients. Products of conception which are seen protruding from the external OS may be removed with ovum forceps at this time without entering the cervical canal. The patient with incomplete abortion is then given a course of quinine sulfate, 3 grains by mouth every thirty minutes for six doses. Obstetric Pituitrin in 0.5 C.C. doses is administered by hypodermic at the time of the third and sixth doses of quinine. If after six to eight hours the bleeding persists and the uterus does not evacuate spontaneously, a second series of quinine and Pituitrin is given. Unless hemorrhage becomes dangerous the uterus is not invaded. If this management fails to empty the uterus by the second or third hospital day a very gentle curettage with a blunt curette is performed. The cervix is frequently found to be dilated and the uterine contents can be lifted out with ovum forceps. Packing is not used for fear of increasing the hazard of infection. During the past several years the census of the Obstetric Division has increased and with it the number of women admitted with the diagnosis of abortion (Table I). The number of beds assigned to the division has not increased in proportion to the demand, hence there is an urgent need for a more prompt turnover of patient load. In the calendar year of 1949, 1,683 patients with abortions were admitted to the Cook County Hospital (Table II). It will be noted that a relatively small number of threatened abortions arrive on our ward for two obvious reasons: first, many of the our patients have heavy home responsibilities and will not leave their families unless they are seriously ill, and, second, many 1327

.im.

TABLE 1943

1944

deaths

s

1951

I 1946 __----?lO,OZO 1,543

1945

No. of patients admitted -~~----. 8,%~-~?,%?~--’ Cases of abortion admittell 1,324 1,200 ion

& Gym..

December.

.-___.

~.~~ ..._.__.

Atwrt

J. Obst.

1,028 r,

5

__- 1947 11,980 2,034 3

1948 13,610 1,957 2

1949 12,342 1,683 3

---.

2

l~sons applying at the emergency room of this huge county hospital must be sent home because bed space for patients with milder complaints is not available. The abortions in progress classified as incomplete and inevitable constitute 60.9 per cent of the current series and 67.4 per cent of the Hillis series. The complete abortions constituted a larger percentage of the older group, doubtless because greater apprehension then prevailed concerning morbidity and mortality and the admitting room intern was more relucta.nt to send such patients home. The percentage of patients with sepsis is similar in the two groups, 16.4 per cent in the current series and 14.7 per cent in the previous b. wl’ies. b -.~~~ -_

-.~~~

~~--

TABLE 11. CLASSIFICATION -~ -~-~.~.. I_-____ / CURRENT SERIES,

OF ABORTIONS ---.-_ __ 194g1---

SEyE::*:;;NT

___~-

'Fhreatened

lncomnlete Complke Septic (all Therapeutic Missed Total

;;*L"'"

62 683 82 150 38 -__-. 0

and inevitable types)

’ 68 “80 4 13 1,683

4.0 16.6 0.2 0.8 100.0

6.1 67.4 8.1 14.7 3.7 0.0 100.0

1,015

-~-

It is gratifying to note that the number of therapeutic abortions has decreased from thirty-eight (3.7 per cent) to four (0.2 per cent). One of the explanations for this reduced figure is that we are no longer forced to evacuate uteri for unmanageable hyperemesis gravidarum.” Liberal use of vitamins in the treatment of these sufferers has almost eliminated the grave consequences once resulting from hyperemesis gravidarum starvation. It is aIso rare today ior us to empty a uterus in either the tuberculous or the cardiac3 patient. Three I herapeutic abortions were performed for hypertensive cardiovascular disease itt 1949 and one was peformed on a patient with advanced tuberculosis. -.--

.__-__) I

Dontaneous Ecaeuated DiIatation Within (not Within Within Within FYithin Keadmission l’otal

__.__~ or Pituitrin and ouinine immediately because’ IIf lwn~orrl~~gc and curettage first day of admission emergency) second day of admission third day of admission fourth day of admission fifth day of admission for bleeding

I

AGTHOR'SSERIES

1949 332 41 649

70 214 204 H-l 77 _. .~ _____.16 1,038

'----

HILLIS SERIES

1939 I ~~.---___531 38

114 --.~.-.-.-___-_..-~ 28

The ultraconservative management of incomplete or inevitable has given way to an increasing number of curettements (Table III).

711

abortions In 1939

Volume Number

ABORTION

62 6

AT COOK COUNTY

HOSPITAL

1329

only one in five patients had surgical interference; in 1949 two patients were evacuated with ovum forceps or curette to one who was treated entirely conservatively. In the Hillis series 114 afebrile patients were kept in the hospital five days with normal temperature before a dilatation and curettage were undertaken. In the recent group, 488 patients were surgically treated in the first three hospital days. This more active management has materially reduced the length of hospital stay. The average hospital stay for the abortion patients without fever in 1949 was 5.07 days, as compared with 8.6 days for the Hillis series. The average hospit,al stay for the patients with fever (Table IV) was 7.02 and 11.9 days, respectively. With the more prompt treatment and the use of antibiotics and abundant blood, the morbidity and mortality have progressively decreased. TABLE

IV.

SEPTIC

ABORTIONS

/ Complete Incomplete* Incomplete

or

within

1

HILLIS 1939 SERIES

13

threatened

33

1 or

inevitable

Total *Died

*yg?

thirty

minutes

of

admission

before

266

117

280

150

treatment

could

be

instituted.

For the purpose of this study, patients were considered septic who had a temperature of 100.4O F. In our series there were 280 (16.6 per cent) such patients and in the Hillis series 150, or 14.7 per cent. The morbidity figures are shown in Table V. There was no serious sepsis in the emergency group treated in 1949 and none had fever after the third day. Of the 17 patients evacuated because of serious hemorrhage in 1939, 8 patients, or 47 per cent, had fever lasting from four to seven days; 3, or 17 per cent, had fever lasting from eight to ten days, while 2, or 11.8 per cent, were sept,ic more than eleven days. Of the septic cases treated with quinine and Pituitrin 26.3 per cent of the 1939 group had fever for more than four days and 15 per cent for more than eight days as compared with 6.1 per cent and 0.9 per cent in the present series. Although infection continues to be the greatest hazard to the patient with abortion, hemorrhage may also cause death49 5 or seriously endanger life by reducing resistance to infection. Shock from hemorrhage was present in 47 women upon admission to the ward (Table VI) and 12 patients developed shock These 59 patients received a total of 60,500 C.C. of whole while in the hospital. blood and 8,900 C.C. of plasma. The smallest amount given to one patient was 250 CC. of plasma and the largest amount was 3,500 C.C. of whole blood. In addition to those treated for shock, 153 women were transfused for marked anemia and/or sepsis. In the total group transfused there were only 4 reactions. One patient developed shock with a blood pressure of 70/40 following dilatation and curettage. She had a mild reaction from 250 C.C. of plasma, The other 3 patients were given blood for marked anemias. Two of these were afebrile when admitted to the hospital and had peak temperature elevations of 104O F. for two days and 102“ for one day, respectively. The fourth patient had a temperature of 102.6O F. when admitted to the hospital and was febrile for a total of three days. This transfusion reaction rate of 0.97 per cent compares favorably with that of bank blood in other institutions.s

Volume 62 Number 6

ABORTION

AT

COOK

COUNTY

1331

HOSPITAL

It is little wonder that before antibiotic and chemotherapeutic drugs! curetWith the present therapeutic aids, tage was considered a grave undertaking. selected patients may be given more active treatment safely. They can be released from the hospital more promptly without jeopardizing their well-being. Conservative therapy reduced the abortion mortality as reported by Hillis from 20 per thousand in 19247 to 10 per thousand in 1939.l In this report of 1,683 abortions treated at the Cook County Hospital in 1949 there were only two deaths, both of them of patients who were fatally infected upon admission to the hospital. These fatalities are abstracted and represent an uncorrected mortality of 0.11 per cent. TABLE

VI.

BLOOD

AND PLASMA

TRANSFUSIONS

NO. PATIENTS 59 153 Total

INDICATION Shock 47 admitted in shock 12 shock on ward Marked anemia and/or sepsis

212

A?dOUNT

AMOUNT 47 11

48,500 12,000

C.C. C.C.

14 3

7,650 1,250

C.C. C.C.

153 211

118,500 179,000

C.C. C.C.

11 28

5,100 14,000

C.C. C.C.

1949.

The

Mortality CASE I.-B. W., aged 2F years, gravida i, para 0, was admitted of the last menstrual period was not available. The patient was treated at an outside hospital for incomplete Aug. 5 to 19, 1949. Treatment consisted of sulfadiazine, penicillin, At the time of admission, her temperature was 105” F. and died shortly after arrival in the ward before any treatment could be Coroner ‘s Necropsy : Puerperal endometritis with ulcer in wall

Aug.

19,

date

criminal abortion from and streptomycin. she was moribund. She instituted. of uterus. Septicemia.

CASE 2.-B. J., aged 19 years, gravida i, para 0, was admitted June 19, 1949. The menstrual period had been April 7, 1949. She had had two “vaginal” packings in May, aud had bled profusely after the second pack was removed. There was a foul odor. On admission, she was acutely ill, with a temperature of 101” F., pulse 104, and respirations 32. The skin had a golden orange hue. The sclera were markedly jaundiced. There were slight stiffness of the neck and jaws? and marked tenderness and rigidity of the lower abdomen. Placental tissue was lying free in the vagina and cervical OS. A catheterized specimen of urine was black. Placental tissue was removed with ring forceps from the external cervical OS. Penicillin, fluids, vitamins, streptomycin, and 2,000 C.C. blood were administered. Levine suction was instituted and oxygen was given. She was in the hospital 11 days. Coroner’s Neoropsy : Septieopyemia arising in a recently pregnant (gangrenous placenta) infectcll uterus.

last

Summary

and Conclusions

1. The treatment of abortions at the Cook (lounty Nospji.al in 1949 is (VIIIpared with that reported by Hillis in 1939. 2. The treatment of the patient with abortion is outlined. (.tonservative management of septic patients is still the procedure of choice. 3. Incomplete and inevitable abortions constituted 60.9 per cent of this series and 67.4 per cent of the previous series.

I 332

WEBSTEX

4. Therapeutic

abortions

have markedly

Ana. J. Obst. & Gyuec. Deem her. 195 I

decreased from 3.7 per cent to

0.2 per cent. 5. This series demonstrates that with available chemotherapy and antibiotics evacuation of the uterine contents in the afebrile patient with incomplete abortion shortens the hospital stay, lessens the blood loss, and is without danger. 6. The greatest hazard to the patient with abortion continues to be infect,ion, although hemorrhage may cause death or seriously endanger life by reducing resistance to infection. Shock was present i’. Hemorrhage is a serious complication of abortion. iit 59 women and was treated vigorously with whole blood and plasma. In addition, 153 women were transfused for marked anemia and/or sepsis. 8. Morbidity and mortality figures are given.

References 1. Hillis,

2. 3. 4. 5. 6. 7.

Proc. Am. Congress on Obst. & Gynec. 1: 27, 1941. Fitzgerakl, J. E., and Webster, Augusta: Ax. J. OBST. $ i?Yi?EC. 1: 483, 1939. Fitzgerald, J. E., Webster, Augusta, Zummo, B. P., and Williams, I?. C.: J. A. M. A. 146: 910, 1951. united St&es Public Health Service, National Cfiice ot’ Vital Statistics: Kational Snnlmark: Deaths and Death Bates for Each Cause 35: 11, May 15, 1819. Pastore,, J. 13.: Proc. Am. Congress on Obst. 8; Gynec. 1: 483, 1939. De Gown, E. L.: J. Iowa K Sm. 35: 136, 1945. Hillis, D. 8.: Snrg., Gvner. & Ohst. 38: 83, 1924. 104

D. S.:

SOUTII

MICIIIGAX

fivENIX