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The risk of death from combined abortion-sterilization procedures: Can hysterotomy or hysterectomy be justified?
The risk of death from combined abortion-sterilization procedures: Can hysterotomy or hysterectomy be justified? HAN1
I(.
ATRASH,
HERBERT I WILLARD DAVID
B.
M.D.
PETERSON,
CATES, A.
GRIMES,
JR.,
M.D. M.D.,
M.P.H.
M.D.
Atlanta, Georgk Clinicians have debated whether women who request permanent sterilization when they undergo elective abortion should have the two operations done concurrently. Moreover, if the procedures are performed concurrently, the appropriate surgical approach is unknown. To evaluate the latter issue, we identified all concurrent abortion-sterilization deaths in the United States in the period 1972 to 1978 from the Centers for Disease Control’s nationwide surveillance of abortion mortality and divided them into two groups: those who had hysterotomy with tubal ligation or hysterectomy (H/H) and those who had curettage or instillation procedures, with tubal ligation by laparoscopy or laparotomy (other procedures). We then used data from the Joint Program for the Study of Abortion (JPSA/CDC) to estimate the number of procedures done in the United States in the period 1972 to 1978 and calculated death-to-case rates for each group. We found that the risk of dying from a concurrent abortion-sterilization procedure was 3.3 times higher if done by H/H. The relative risk for this group was highest during the first 12 weeks of gestation (4.6) and lowest at 13 weeks or later (1.3), regardless of the presence or absence of preexisting medical conditions. Except in the rare instances where the woman has an indication for hysterectomy other than fertility control, the performance of hysterectomy or hysterotomy for concurrent abortion-sterilization, particularly at less than 13 weeks’ gestation, does not appear justified. (AM. J. OBSTET. GYNECOL. 142:269, 1982.)
SOME WOMEN who request elective abortion also desire permanent sterilization. These two operations can be done concurrently, or sterilization can be done some weeks after abortion (interval sterilization).‘, * When a woman chooses concurrent sterilization, she and her physician must decide which approach offers the safest
From the Abortion Surveillance Branch and the Epidemiologic Studies Branch, Family Planning Evaluation Division, Caters for Disease Control. Receivrd Rwked Accepted
for publication September September
April
22, 1981.
I, 1981. 8, 1981.
Reprint requests: David A. Grimes, M.D., Abortion Surveillance Branch, Family Planning Evaluation Division, Center for Health Promotion and Education, Ce&ers jar Disease Control, Atlanta, Georgia 30333.
and most effective means of terminating the existing pregnancy 2nd preventing future pregnancies. Some authors have recommended hysterotomy 01 hysterectomy for those women who desire concurrent abortion-sterilization.’ 3, 4 Others have claimed that hysterotomy and hysterectomy place the patient at a dramatically increased risk of morbidity and mortality, .3-i Recent studies have demonstrated that suction curettage abortions, combined with concurrent sterilization by either laparoscopy” or minilaparotomy,’ have low complication rates. No comparative studies, however. have directly examined the risks of’ abortion combined with sterilization either by laparoscopy or minilaparotomy or by hysterotomy with tubal ligation or hysterectomy. In this report data are used from the United States for the period 1972 to 1978 to compare the risk of death from abortion via hysterotomy and 269
270
Atrash et al.
tubal ligation or hysterectomy concurrent abortion-sterilization.
with other procedures
of’
Methods We identified deaths through the Centers for Disease Colltrol’s (CDC) nationwide surveillance of abortion morralirv. The melhods of this surveillance have been reported in detail.h We then categorized by type of procedure all deaths related to concurrent abortion-sterili/.ation that occurred from January I, 1972, through December 31. 1978. Prcocedures were classifed as either (I ) hysterotomy with tubal ligation or hysterectom) or (2) other abortion procedures (e.g., curettage, instillation of abortifacient) with tubal occlusion (by laparoscopy or laparotomy). ‘To determine the denominators necessary to calcukc the death-to-case rates, we used information from CDC’s national abortion surveillancex and from the Joiltr t’rog:ram for the Study of Abortion under the aLlspices of the Centers for Disease Control (JPSAi CDC:‘t.” We applied JPSAiCDC proportions of concurJYJIJ ;litorLion-sterili/.ation procedures to the total number of abortions performed in the United States; this enabled us to estimate the number of concurrent abortion-sterilizatiorls by type of procedure. These numbers we1.c compared with numbers obtained by CDC’s national surveillance of sterilizing operations.“‘, ” Finally, we classified all combined abortion-sterilization procedures b! three factors, based or1 JPSAiCDC distriburions: (1) the presence OJ- absence of a preexisting medical condition, (2) the gestational age at which the procedure was performed, and (3) the type of anesthesia used.
Results Clinical characteristics. Among women obtaining abortion in the United States in the period 1972 to 1978, li1.e died after hysterectomy procedures and three died after- hysterotomy with tubal ligation (H/H): 14 died after other procedures of abortion and concurIrent sterilization (others) (Tables I and II). The ages of’ thehe 22 women ranged between 20 and 44 years, with a mean of 32 years (35 years for H/H and 31 for others). Parity ranged between 0 and 8, with a mean of :I .O. Twelve wotnen had preexisting medical conditions (six H/H and six others). Nine died of pulmonary embolism (three Hi H and six others); three died of complications of general anesthesia (one H/H and two others); three died of intra-abdominal hemorrhage (one H/H and two others); one H/H patient died of amniotic fluid embolism, and another died of preexisting heart disease; three patients who had other procedures died of peritonitis-sepsis: and one died of cere-
bra] hypoxia. In one H/H case, the (‘iuse ol ck,trl~ could not be determined. Death-to-case rates. When we applied tlreJPS.-\!(.IK: proportions to the total number of ,kbortion\; IX*~ formed in the United States, we estimaketi that,-dl,i.ing (he se\‘etl-kear period 1972 to 1978, ,111 averagt’ of 20,560 women per year obtained COIICU~J cm ;~hmot~sterilizations. a total of 143,910 in 7 years. CDC’s burgical sterilization surveillance data indicate similar- c,ytimates.“‘. ” The similarity of’ these estimates supports their credihilit~~. Using these’estimations, we f’out~l t/m the over,111 death-to-case rate for concurrent abortion-sterilization w;1 1.5.3 per 100,000. For abortions 1,) lH!H, the crude death-to-case rate was 37.3 per 100,OOU. and fog, those by suction curettage, dilation and evacuation, 01‘ instillation combined with tubal ligatiolt, the crude death-to-case rate was 11.~4 per 100,001) (Table III). ‘I‘hree factors may elevate the crude death-to-cast. rate for Hi H compared with other procedures: pree.xisting conditions, gestational age, and tape of’ anesthcsia. We adjusted for the effect of preexisting medical conditions by applying relevant percentages from the JPSAiCDC study. We assumed that :32’i; o!’ w\‘o1ne11 who had concurrent abortion-sterilization b\ 11%SIC’J-cctomy OJ- hvsterotom!. and 16’;: of those v,ho llad c-011current abortion-sterilizations by other procedures had serious preexisting conditions at the lime of operation. We divided both numerators AJK~ denominators into two categories: those who had a preexisting medical condition and those who did not. ‘rhis adjustment reduced the Hi H death-to-case rate to 13.8 per 100.000 f.or- those without a preexisting medical c.olltiition ;IJI~ increased Ltie rate to 87.7 per 100.000 for those v;ith ;I preexisting medical condition (Table I I I). .-\ c-omparable reduction to 7.8 deaths per 100,000 procedures was obtained tor abortion-sterilization pertor-med I,\ OI IWJ procedures on women with JW precxiating medical conditions: an increase to 30.6 per 100.000 was ohrained for those with a preexisting medical contlition (Table 111). The.JPSA/CDC study also provided ttlc- babis ~OJ. WI assumption that 43% of H/H and 87% of‘ other coIlcurrent abortion-sterilizations were done at 5 12 weeks ot’ gestation. This percentage was applied to total I--I/I I and other concurrent abortion-sterilizations to estimate the numbers of procedures in each category. W’hen 1%~ used those estimated numbers to calculate gestational age-specific death-to-case rates. we found that the rate of H/H was higher if the procedure was done at the earlier gestational age (43.5 for 5 12 weeks and 32.8 fol 213 weeks). However, the rate for the other llrocedures was higher if the procedure was (lone at the later
Risk of death
Volume Number
142 5
Table
I. Deaths from hysterectomy Method of ubortionstwilization
Patient .VO.
2
Hysterectomy Hysterectomy
3 ‘I
Hysterectomy Hysterectomy
5 6
Hysterectomy Hysterotomy
7
Hysteroromy
8
Hysterotomy
1
and hysterotomy
for abortion
from
and sterilization,
United
procedures
271
States, 1972-1978
Gestational Pre-existing condition
Hypertension Obesity Hypertension Previous pelvic inflammatory disease Leiomyomas Heart disease Hypertension Collagen vascular disease None Obesity Leiomyomas Obesity Hypertension 3 previous cesarean sections None
gestational age (9.4 at 512 weeks and 25.1 at ~13 weeks). When we controlled for preexisting medical conditions, the risk of dying from H/H procedures was 2.9 times more than that from other procedures for women who had preexisting medical conditions but only 1.X times more for women who did not have preexisting medical conditions (Table 111). When we controlled for gestational age, we found that the risk of‘ dying from H/H procedures was -1.6 times more than that from other procedures during the first 12 weeks of gestation but only 1.3 times more after 12 weeks of gestation (Table 111). To control for type of anesthesia, we adjusted on11 the death-to-case rate for concurrent abortion-sterilization procedures performed by methods other than H/H, since all deaths after H/H procedures involved the use of general anesthesia. We subtracted from the numerator in the “other procedures” group the one death that occurred when local anesthesia was used, and we deleted from the denominator the estimated number of concurrent abortion-sterilization procedures performed with local anesthesia during 1972 to 1978 (16,690 procedures). This adjustment resulted in a death-to-case rate of 12.3 per 100,000 for concurrent abortion-sterilization performed by procedures other than H/H with general anesthesia and a rate of 6.0 per 100,000 for procedures performed with local anesthesia. The death-to-case rate for all procedures (H/H plus others) done with general anesthesia was 15.3 per 100,000.
Comment The safety of concurrent abortion-sterilization versus abortion followed by interval sterilization has been
from
age (weeks menstrual period
abortion-sterilization
lad
Cau.w of de&h
10 13
Pulmonary embolism Irma-abdominal hemorrhage
10 22
Heart disease Pulmonary embolism
10 14
Unknown Pulmonary embolism
11
General anesthesia complication
17
Amniotic fluid embolism
debated. Some studies indicate that suction curettage abortions performed concurrently with either laparoscopy or laparotomy sterilization have complication rates no higher than suction curettage followed by interval sterilization.‘, “, I’ Others indicate that although a concurrent abortion-sterilization procedure may be effective and convenient, it carries an increased risk of complications.‘:‘, ” When concurrent abortion-sterilization is chosen, the safety of the combined procedure must be considered. We found that the option of hysterectom)- or hysterotonly carries a 1.3 to 4.6 times greater risk of death than curettage or instillation combined with tubal ligation (Table III). The greatest difference in death-to-case rates between H/H and other procedures was when the operation was performed at 512 weeks of’ gestation (Table III). When performed at ~13 weeks, the risk of the other procedures approaches that of H/H. This is primarily because the risk of the other procedures increases as gestational age increases: the risk of uterine evacuation procedures is dependent on gestational age, whereas that of H/H is less so. Because of the small numbers of deaths, the 95% confidence intervals around the H/H rates are broad: the H/H rates at 512 and 2 13 weeks’ gestation are not significantly different at p < 0.05. Thus, it appears that as gestational age increases, the choice of the appropriate procedure for concurrent abortion-sterilization becomes less clear. Convenience and cost are also factors to be considered in choosing a procedure for concurrent abortion-sterilization.‘“. Iti The average length of hospital stay for hysterectomy in the United States in 1975 was 10 days.” In contrast, concurrent abortion-sterilization through other means can now be performed on an outpatient basis.“. I1 H );sterectom) mav be more convenient only
272
Atrash et al.
Table II. Deaths from suction curettage and instillation dnd sterilization. United States, 1972 to 1978
procedures
with concurrent
ATL
Eisenmenger’s syndrome AsLhma Pulmonary 1uberculosis Poorlv differentiated Iymphocytitlet!!irmia None
I ti
cu-
Laparoscopy
None
17
cu-
ATL
i%one
IU
cu-
ATL
None
x
cu-
Laparoscopy
None
x
ATL
None
x
Suction curettage Suction Cl,rruage
ATL
Sucrion curettage
ATL
Suction rettage Suction r-ettage Suction rettage Suction
cl*-
Kane
rettage Suction curettage Suction curettage Suction curettage
A’TL
Dilation and ex ac uation
Sharp curettage Saline instillation ATL
= Abdominal
tubal
11
ATL
None
10
Laparoscopy
Obesity
I-1
Hypertension Pulmonary dosis
we
Eisenmenger’s syn-
h&GlrOSCOpy
drome Hypertension
demonstrated
that
the
risk
of
indi(e.g.. death
would
be performed
with
local
anesthesia.
If
anesthesia is increasingly used for abortion, its relative safety may produce an even more pronounced future difference in risks for H/H compared with other concurrent abortion-sterilization procedures. Our death-to-case rates suggest that the risk of death local
embo-
C;eneral anesthesia complication Pulmonary embolism Cerebral hypoxia
Pulmonary embolism Pulmonary embolisnl Pulmonary embolicm Intra-abdomirui brmorrhage
x 18
Intra-abdominal hemorrhage Peritonitis
ligation.
trom induced abortion was two to four times greatel when general rather than local anesthesia was used (unpublished data). The present study reveals that there is a 2.8-fold higher risk of dying from a concurrent abortion-sterilization procedure done with general anesthesia than one done with local anesthesia. This difference influences the choice of procedure for concurrent abortion-sterilization, because both induced abortion3 and sterilization”’ can be perf’ormed with local anesthesia. It is unlikely that hysterectomy or hysterotomy
Pulmonary lism Sepsis
sarcoi-
ATL
for those relatively few women who have current cations for the operation other than sterilization leiomyomas). Recently,
tvr abornon
8
rettage
Suction
tubal ligation
from concurrent abortion-sterilization is greater when performed by H/H than when performed by curettage or instillation with tubal ligation. However, these comparisons have several limitations. First, because rhe numerators are small, small changes in the number of deaths result in relatively large increases in the deathto-case rates. However, even though chance may affect these rates, the magnitude of the relative risk implies that a real difference exists. A second possible limitation is that our denominator5 are estimates based on extrapolations from an observational study to national abortion data. We assumed that the JPSA/CDC data accurately reflect lhe characreristics of abortions performed in the United States in the period 1972 to 1978. To the extent that this assumption is erroneous, our denominators will be incorrect. However, because the denominators are so large, it would take major errors in our estimates to influence substantially the death-to-case rates. Moreover. comparison of our denominator estimates with those
Risk of death from abortion-sterilization
Table III. Estimated death-to-procedure preexisting conditions, and gestational No. of
cases:
Preexisting condition Yes No
deaths
Dpath-to-/medure rater *
No. of procedures
273
by type of procedure,
Relatiue mk (95% confidmcr
Others
HIH
Others
HIH
Others
intmd)t
8
14
21,370
122,540
37.4
1 1.4
3.3 (1.4-7.4)t:
6
6 8
6,840 14,530
19,610 102,930
87.7
2
13.8
30.6 7.8
2.9 (0.9-8.4) 1.8 (0.4-8.2)
4 4
10 4
9,190 12,180
106,610 15,930
43.5 32.8
9.4 25.1
4.6 (1.6-13.3)$ 1.3 (0.3-5.2)
HIH All
rates for concurrent abortion-sterilization age, United States, 1972 to 1978
procedures
Gestational age 112 213
wk
wk
*Deaths per 100,000 procedures. tRisk of death from H/H compared to others. T’he 95% confidence interval is in parentheses. When the interval does not overlap 1.O, the difference is statistically significant at p < 0.05 marked by f).
from CDC’s national sterilization surveillance activities showed similar numbers of combined abortion-sterilization procedures during our study period. A third consideration relates to the comparability of two groups. The H/H group had a mean age 4 years greater than that of the other group. While death-tocase rates for most operations increase with advancing patient age, the 3-year difference in age cannot be espetted to account for more than for a threefold higher relative risk. Controlling preexisting conditions lowered but did not eliminate the greater relative risk of death from H/H. Finally, some clinicians may question our combining hysterectomy and hysterotomy procedures in calculating an aggregate death-to-case rate. While we can separate these procedures in the numerators, this is not feasible for the denominators, since many states aggregate hysterectomy and hysterotomy in their annual reports to CDC. The JPSAiCDC study suggests that combining these procedures for analysis is reasonable, since both have similar morbidity rates, which are significantly higher than those of either instillation or curettage abortions.” Moreover, if hysterotomy and
hysterectomy were separated for analysis, the problem of already small numbers of deaths would be aggravated, making death-to-case rates lrss reliable because of the possible influence of chance occurrence of these infrequent events. In conclusion, performing concurrent abortion-sterilization by hysterectomy or hysterotomy rather than b> curettage or instillation with tubal ligation carries a 1 .&fold to 4.6-fold increased risk of death. The clinical implications of these findings are straightforward: Major surgery for abortion-sterilization is more hazardous than alternative methods. Overall, women who underwent H/H were more than three times as likely to die from the operation, with most of this difference occurring in the first trimester. Both women and physicians should be aware of the magnitude of this risk when the! choose a method for concurrent abortion-sterilization. Unless the wuman has an indication for hysterectomy other than fertility control, the performance of hysterectomy or hysterotomy for concurrent abortion-sterilization does not appear to bejustitied. particularly at less than 13 weeks’ gestation.
REFERENCES
1. Cheng, M. C. E., Cheong, J., Chew, S. C., Choo, H. T., and Ratnam, S. S.: Safety of postabortion sterilization
compared with interval sterilization, Lancet 2:682, 1979. 2. Whitson, L. G., Ballard, C. A., and Israel, R.: Laparoscopic tubal sterilization coincident with therapeutic abortion by suction curettage, Obstet. Gynecol. 41:677, 1973. 3. Stumpf, P. G., Ballard, C. A., and Lowensohn. R.: Abdominal hysterectomy for abortion-sterilization, AM. J. OBSTET. GYNECOL. 136:714, 1980. 4. Atkinson. S. M.: Vaginal hysterectomy: the ideal abortion
in multiparous
patients,
South.
Med.
J. 67:134,
1971.
5. Schulman, H.: Major surgery for abortion and sterilization, Obstet. Gynecol. 40:738, 1972. 6. Priver. D. M.: Abortion-sterilization by abdominal hysterectomy, AM. J. OBSTE:T. GYNECOL. 139:115, 1981. 7. Sloan, D.: Abortion-sterilization by abdominal hysterectomy, AM. J. OBSTET. GYNECOL. 139:116, 1981.
8. Centers for Disease Control: Abortion issued November, 1980. 9. Grimes,
D. A., Schulz,
K. F., Cates,
Surveillance 1978. W.. Jr.,
and
Tyler,
274
Atrash
et al.
C. W., Jr.: Local tar performing
10. 11.
!L’.
13.
versus general anesthesia: Which is safer suction curettage abortions? AM. J. OBSI’F:T. GYSECOL. 135:1030, 19%. Centers for Disease Control: Surgical Sterilization Surveillance. Tubal Sterikation 1970-1975. issued July, 1979. Center-s f’oor Disease Control: Surgical Sterilization Su-veillance. Hysterectomy in women aged 1.5~+I, 197019i5. issued September, 1980. (Zheng:. If. C. E.. and Rochat, R. \V.: The saf’et!. of cornbined abortion-sterilization procedurw, AM, J, OBSTFX. (~i~xr.c.ar.. 129:.5#. 1977. \\:cil, .-I .: Laparoscopic sterilization with rherapeutic abortion versus sterili;ration ot‘ abortion alone, Obstet. Gynet 01. 52:79, 197x.
14.
Hernandel, I. M., Perry, G., KatL, X. K., and Held. K.: Postabortal laparoscopic tubal sterilization. results in comparison to interval procedures, Obstet. Gvnecol. 50:356. 1977. 15. Haynes. D. M.. Wolfe, W. 41.: ~I’ubal srt:lllv.arion 111 rtl~ indigent population, :%M. ,J. OBSTEI.. GY~ecor.. 106: 10-N. 1970. 16. Muldoon. hl. J.: Gynecological illness ,tt:r,l ~~erdirat~o~l. Br. Med. J, l:A4, 1972. 17. Cares. W., JI-., and Grimes. D.A.: Morbidlt) rind mo]-laji(\ of abortion in the I.‘nited States. i?r Hodgson, J. E., editw : .Ibortion and Sterilization: Medical and Social .A\pec tb, London. 1981, Academic Press, Inc., pp 155 180.
I(.
ATRASH,
HERBERT I WILLARD DAVID
B.
M.D.
PETERSON,
CATES, A.
GRIMES,
JR.,
M.D. M.D.,
M.P.H.
M.D.
Atlanta, Georgk Clinicians have debated whether women who request permanent sterilization when they undergo elective abortion should have the two operations done concurrently. Moreover, if the procedures are performed concurrently, the appropriate surgical approach is unknown. To evaluate the latter issue, we identified all concurrent abortion-sterilization deaths in the United States in the period 1972 to 1978 from the Centers for Disease Control’s nationwide surveillance of abortion mortality and divided them into two groups: those who had hysterotomy with tubal ligation or hysterectomy (H/H) and those who had curettage or instillation procedures, with tubal ligation by laparoscopy or laparotomy (other procedures). We then used data from the Joint Program for the Study of Abortion (JPSA/CDC) to estimate the number of procedures done in the United States in the period 1972 to 1978 and calculated death-to-case rates for each group. We found that the risk of dying from a concurrent abortion-sterilization procedure was 3.3 times higher if done by H/H. The relative risk for this group was highest during the first 12 weeks of gestation (4.6) and lowest at 13 weeks or later (1.3), regardless of the presence or absence of preexisting medical conditions. Except in the rare instances where the woman has an indication for hysterectomy other than fertility control, the performance of hysterectomy or hysterotomy for concurrent abortion-sterilization, particularly at less than 13 weeks’ gestation, does not appear justified. (AM. J. OBSTET. GYNECOL. 142:269, 1982.)
SOME WOMEN who request elective abortion also desire permanent sterilization. These two operations can be done concurrently, or sterilization can be done some weeks after abortion (interval sterilization).‘, * When a woman chooses concurrent sterilization, she and her physician must decide which approach offers the safest
From the Abortion Surveillance Branch and the Epidemiologic Studies Branch, Family Planning Evaluation Division, Caters for Disease Control. Receivrd Rwked Accepted
for publication September September
April
22, 1981.
I, 1981. 8, 1981.
Reprint requests: David A. Grimes, M.D., Abortion Surveillance Branch, Family Planning Evaluation Division, Center for Health Promotion and Education, Ce&ers jar Disease Control, Atlanta, Georgia 30333.
and most effective means of terminating the existing pregnancy 2nd preventing future pregnancies. Some authors have recommended hysterotomy 01 hysterectomy for those women who desire concurrent abortion-sterilization.’ 3, 4 Others have claimed that hysterotomy and hysterectomy place the patient at a dramatically increased risk of morbidity and mortality, .3-i Recent studies have demonstrated that suction curettage abortions, combined with concurrent sterilization by either laparoscopy” or minilaparotomy,’ have low complication rates. No comparative studies, however. have directly examined the risks of’ abortion combined with sterilization either by laparoscopy or minilaparotomy or by hysterotomy with tubal ligation or hysterectomy. In this report data are used from the United States for the period 1972 to 1978 to compare the risk of death from abortion via hysterotomy and 269
270
Atrash et al.
tubal ligation or hysterectomy concurrent abortion-sterilization.
with other procedures
of’
Methods We identified deaths through the Centers for Disease Colltrol’s (CDC) nationwide surveillance of abortion morralirv. The melhods of this surveillance have been reported in detail.h We then categorized by type of procedure all deaths related to concurrent abortion-sterili/.ation that occurred from January I, 1972, through December 31. 1978. Prcocedures were classifed as either (I ) hysterotomy with tubal ligation or hysterectom) or (2) other abortion procedures (e.g., curettage, instillation of abortifacient) with tubal occlusion (by laparoscopy or laparotomy). ‘To determine the denominators necessary to calcukc the death-to-case rates, we used information from CDC’s national abortion surveillancex and from the Joiltr t’rog:ram for the Study of Abortion under the aLlspices of the Centers for Disease Control (JPSAi CDC:‘t.” We applied JPSAiCDC proportions of concurJYJIJ ;litorLion-sterili/.ation procedures to the total number of abortions performed in the United States; this enabled us to estimate the number of concurrent abortion-sterilizatiorls by type of procedure. These numbers we1.c compared with numbers obtained by CDC’s national surveillance of sterilizing operations.“‘, ” Finally, we classified all combined abortion-sterilization procedures b! three factors, based or1 JPSAiCDC distriburions: (1) the presence OJ- absence of a preexisting medical condition, (2) the gestational age at which the procedure was performed, and (3) the type of anesthesia used.
Results Clinical characteristics. Among women obtaining abortion in the United States in the period 1972 to 1978, li1.e died after hysterectomy procedures and three died after- hysterotomy with tubal ligation (H/H): 14 died after other procedures of abortion and concurIrent sterilization (others) (Tables I and II). The ages of’ thehe 22 women ranged between 20 and 44 years, with a mean of 32 years (35 years for H/H and 31 for others). Parity ranged between 0 and 8, with a mean of :I .O. Twelve wotnen had preexisting medical conditions (six H/H and six others). Nine died of pulmonary embolism (three Hi H and six others); three died of complications of general anesthesia (one H/H and two others); three died of intra-abdominal hemorrhage (one H/H and two others); one H/H patient died of amniotic fluid embolism, and another died of preexisting heart disease; three patients who had other procedures died of peritonitis-sepsis: and one died of cere-
bra] hypoxia. In one H/H case, the (‘iuse ol ck,trl~ could not be determined. Death-to-case rates. When we applied tlreJPS.-\!(.IK: proportions to the total number of ,kbortion\; IX*~ formed in the United States, we estimaketi that,-dl,i.ing (he se\‘etl-kear period 1972 to 1978, ,111 averagt’ of 20,560 women per year obtained COIICU~J cm ;~hmot~sterilizations. a total of 143,910 in 7 years. CDC’s burgical sterilization surveillance data indicate similar- c,ytimates.“‘. ” The similarity of’ these estimates supports their credihilit~~. Using these’estimations, we f’out~l t/m the over,111 death-to-case rate for concurrent abortion-sterilization w;1 1.5.3 per 100,000. For abortions 1,) lH!H, the crude death-to-case rate was 37.3 per 100,OOU. and fog, those by suction curettage, dilation and evacuation, 01‘ instillation combined with tubal ligatiolt, the crude death-to-case rate was 11.~4 per 100,001) (Table III). ‘I‘hree factors may elevate the crude death-to-cast. rate for Hi H compared with other procedures: pree.xisting conditions, gestational age, and tape of’ anesthcsia. We adjusted for the effect of preexisting medical conditions by applying relevant percentages from the JPSAiCDC study. We assumed that :32’i; o!’ w\‘o1ne11 who had concurrent abortion-sterilization b\ 11%SIC’J-cctomy OJ- hvsterotom!. and 16’;: of those v,ho llad c-011current abortion-sterilizations by other procedures had serious preexisting conditions at the lime of operation. We divided both numerators AJK~ denominators into two categories: those who had a preexisting medical condition and those who did not. ‘rhis adjustment reduced the Hi H death-to-case rate to 13.8 per 100.000 f.or- those without a preexisting medical c.olltiition ;IJI~ increased Ltie rate to 87.7 per 100.000 for those v;ith ;I preexisting medical condition (Table I I I). .-\ c-omparable reduction to 7.8 deaths per 100,000 procedures was obtained tor abortion-sterilization pertor-med I,\ OI IWJ procedures on women with JW precxiating medical conditions: an increase to 30.6 per 100.000 was ohrained for those with a preexisting medical contlition (Table 111). The.JPSA/CDC study also provided ttlc- babis ~OJ. WI assumption that 43% of H/H and 87% of‘ other coIlcurrent abortion-sterilizations were done at 5 12 weeks ot’ gestation. This percentage was applied to total I--I/I I and other concurrent abortion-sterilizations to estimate the numbers of procedures in each category. W’hen 1%~ used those estimated numbers to calculate gestational age-specific death-to-case rates. we found that the rate of H/H was higher if the procedure was done at the earlier gestational age (43.5 for 5 12 weeks and 32.8 fol 213 weeks). However, the rate for the other llrocedures was higher if the procedure was (lone at the later
Risk of death
Volume Number
142 5
Table
I. Deaths from hysterectomy Method of ubortionstwilization
Patient .VO.
2
Hysterectomy Hysterectomy
3 ‘I
Hysterectomy Hysterectomy
5 6
Hysterectomy Hysterotomy
7
Hysteroromy
8
Hysterotomy
1
and hysterotomy
for abortion
from
and sterilization,
United
procedures
271
States, 1972-1978
Gestational Pre-existing condition
Hypertension Obesity Hypertension Previous pelvic inflammatory disease Leiomyomas Heart disease Hypertension Collagen vascular disease None Obesity Leiomyomas Obesity Hypertension 3 previous cesarean sections None
gestational age (9.4 at 512 weeks and 25.1 at ~13 weeks). When we controlled for preexisting medical conditions, the risk of dying from H/H procedures was 2.9 times more than that from other procedures for women who had preexisting medical conditions but only 1.X times more for women who did not have preexisting medical conditions (Table 111). When we controlled for gestational age, we found that the risk of‘ dying from H/H procedures was -1.6 times more than that from other procedures during the first 12 weeks of gestation but only 1.3 times more after 12 weeks of gestation (Table 111). To control for type of anesthesia, we adjusted on11 the death-to-case rate for concurrent abortion-sterilization procedures performed by methods other than H/H, since all deaths after H/H procedures involved the use of general anesthesia. We subtracted from the numerator in the “other procedures” group the one death that occurred when local anesthesia was used, and we deleted from the denominator the estimated number of concurrent abortion-sterilization procedures performed with local anesthesia during 1972 to 1978 (16,690 procedures). This adjustment resulted in a death-to-case rate of 12.3 per 100,000 for concurrent abortion-sterilization performed by procedures other than H/H with general anesthesia and a rate of 6.0 per 100,000 for procedures performed with local anesthesia. The death-to-case rate for all procedures (H/H plus others) done with general anesthesia was 15.3 per 100,000.
Comment The safety of concurrent abortion-sterilization versus abortion followed by interval sterilization has been
from
age (weeks menstrual period
abortion-sterilization
lad
Cau.w of de&h
10 13
Pulmonary embolism Irma-abdominal hemorrhage
10 22
Heart disease Pulmonary embolism
10 14
Unknown Pulmonary embolism
11
General anesthesia complication
17
Amniotic fluid embolism
debated. Some studies indicate that suction curettage abortions performed concurrently with either laparoscopy or laparotomy sterilization have complication rates no higher than suction curettage followed by interval sterilization.‘, “, I’ Others indicate that although a concurrent abortion-sterilization procedure may be effective and convenient, it carries an increased risk of complications.‘:‘, ” When concurrent abortion-sterilization is chosen, the safety of the combined procedure must be considered. We found that the option of hysterectom)- or hysterotonly carries a 1.3 to 4.6 times greater risk of death than curettage or instillation combined with tubal ligation (Table III). The greatest difference in death-to-case rates between H/H and other procedures was when the operation was performed at 512 weeks of’ gestation (Table III). When performed at ~13 weeks, the risk of the other procedures approaches that of H/H. This is primarily because the risk of the other procedures increases as gestational age increases: the risk of uterine evacuation procedures is dependent on gestational age, whereas that of H/H is less so. Because of the small numbers of deaths, the 95% confidence intervals around the H/H rates are broad: the H/H rates at 512 and 2 13 weeks’ gestation are not significantly different at p < 0.05. Thus, it appears that as gestational age increases, the choice of the appropriate procedure for concurrent abortion-sterilization becomes less clear. Convenience and cost are also factors to be considered in choosing a procedure for concurrent abortion-sterilization.‘“. Iti The average length of hospital stay for hysterectomy in the United States in 1975 was 10 days.” In contrast, concurrent abortion-sterilization through other means can now be performed on an outpatient basis.“. I1 H );sterectom) mav be more convenient only
272
Atrash et al.
Table II. Deaths from suction curettage and instillation dnd sterilization. United States, 1972 to 1978
procedures
with concurrent
ATL
Eisenmenger’s syndrome AsLhma Pulmonary 1uberculosis Poorlv differentiated Iymphocytitlet!!irmia None
I ti
cu-
Laparoscopy
None
17
cu-
ATL
i%one
IU
cu-
ATL
None
x
cu-
Laparoscopy
None
x
ATL
None
x
Suction curettage Suction Cl,rruage
ATL
Sucrion curettage
ATL
Suction rettage Suction r-ettage Suction rettage Suction
cl*-
Kane
rettage Suction curettage Suction curettage Suction curettage
A’TL
Dilation and ex ac uation
Sharp curettage Saline instillation ATL
= Abdominal
tubal
11
ATL
None
10
Laparoscopy
Obesity
I-1
Hypertension Pulmonary dosis
we
Eisenmenger’s syn-
h&GlrOSCOpy
drome Hypertension
demonstrated
that
the
risk
of
indi(e.g.. death
would
be performed
with
local
anesthesia.
If
anesthesia is increasingly used for abortion, its relative safety may produce an even more pronounced future difference in risks for H/H compared with other concurrent abortion-sterilization procedures. Our death-to-case rates suggest that the risk of death local
embo-
C;eneral anesthesia complication Pulmonary embolism Cerebral hypoxia
Pulmonary embolism Pulmonary embolisnl Pulmonary embolicm Intra-abdomirui brmorrhage
x 18
Intra-abdominal hemorrhage Peritonitis
ligation.
trom induced abortion was two to four times greatel when general rather than local anesthesia was used (unpublished data). The present study reveals that there is a 2.8-fold higher risk of dying from a concurrent abortion-sterilization procedure done with general anesthesia than one done with local anesthesia. This difference influences the choice of procedure for concurrent abortion-sterilization, because both induced abortion3 and sterilization”’ can be perf’ormed with local anesthesia. It is unlikely that hysterectomy or hysterotomy
Pulmonary lism Sepsis
sarcoi-
ATL
for those relatively few women who have current cations for the operation other than sterilization leiomyomas). Recently,
tvr abornon
8
rettage
Suction
tubal ligation
from concurrent abortion-sterilization is greater when performed by H/H than when performed by curettage or instillation with tubal ligation. However, these comparisons have several limitations. First, because rhe numerators are small, small changes in the number of deaths result in relatively large increases in the deathto-case rates. However, even though chance may affect these rates, the magnitude of the relative risk implies that a real difference exists. A second possible limitation is that our denominator5 are estimates based on extrapolations from an observational study to national abortion data. We assumed that the JPSA/CDC data accurately reflect lhe characreristics of abortions performed in the United States in the period 1972 to 1978. To the extent that this assumption is erroneous, our denominators will be incorrect. However, because the denominators are so large, it would take major errors in our estimates to influence substantially the death-to-case rates. Moreover. comparison of our denominator estimates with those
Risk of death from abortion-sterilization
Table III. Estimated death-to-procedure preexisting conditions, and gestational No. of
cases:
Preexisting condition Yes No
deaths
Dpath-to-/medure rater *
No. of procedures
273
by type of procedure,
Relatiue mk (95% confidmcr
Others
HIH
Others
HIH
Others
intmd)t
8
14
21,370
122,540
37.4
1 1.4
3.3 (1.4-7.4)t:
6
6 8
6,840 14,530
19,610 102,930
87.7
2
13.8
30.6 7.8
2.9 (0.9-8.4) 1.8 (0.4-8.2)
4 4
10 4
9,190 12,180
106,610 15,930
43.5 32.8
9.4 25.1
4.6 (1.6-13.3)$ 1.3 (0.3-5.2)
HIH All
rates for concurrent abortion-sterilization age, United States, 1972 to 1978
procedures
Gestational age 112 213
wk
wk
*Deaths per 100,000 procedures. tRisk of death from H/H compared to others. T’he 95% confidence interval is in parentheses. When the interval does not overlap 1.O, the difference is statistically significant at p < 0.05 marked by f).
from CDC’s national sterilization surveillance activities showed similar numbers of combined abortion-sterilization procedures during our study period. A third consideration relates to the comparability of two groups. The H/H group had a mean age 4 years greater than that of the other group. While death-tocase rates for most operations increase with advancing patient age, the 3-year difference in age cannot be espetted to account for more than for a threefold higher relative risk. Controlling preexisting conditions lowered but did not eliminate the greater relative risk of death from H/H. Finally, some clinicians may question our combining hysterectomy and hysterotomy procedures in calculating an aggregate death-to-case rate. While we can separate these procedures in the numerators, this is not feasible for the denominators, since many states aggregate hysterectomy and hysterotomy in their annual reports to CDC. The JPSAiCDC study suggests that combining these procedures for analysis is reasonable, since both have similar morbidity rates, which are significantly higher than those of either instillation or curettage abortions.” Moreover, if hysterotomy and
hysterectomy were separated for analysis, the problem of already small numbers of deaths would be aggravated, making death-to-case rates lrss reliable because of the possible influence of chance occurrence of these infrequent events. In conclusion, performing concurrent abortion-sterilization by hysterectomy or hysterotomy rather than b> curettage or instillation with tubal ligation carries a 1 .&fold to 4.6-fold increased risk of death. The clinical implications of these findings are straightforward: Major surgery for abortion-sterilization is more hazardous than alternative methods. Overall, women who underwent H/H were more than three times as likely to die from the operation, with most of this difference occurring in the first trimester. Both women and physicians should be aware of the magnitude of this risk when the! choose a method for concurrent abortion-sterilization. Unless the wuman has an indication for hysterectomy other than fertility control, the performance of hysterectomy or hysterotomy for concurrent abortion-sterilization does not appear to bejustitied. particularly at less than 13 weeks’ gestation.
REFERENCES
1. Cheng, M. C. E., Cheong, J., Chew, S. C., Choo, H. T., and Ratnam, S. S.: Safety of postabortion sterilization
compared with interval sterilization, Lancet 2:682, 1979. 2. Whitson, L. G., Ballard, C. A., and Israel, R.: Laparoscopic tubal sterilization coincident with therapeutic abortion by suction curettage, Obstet. Gynecol. 41:677, 1973. 3. Stumpf, P. G., Ballard, C. A., and Lowensohn. R.: Abdominal hysterectomy for abortion-sterilization, AM. J. OBSTET. GYNECOL. 136:714, 1980. 4. Atkinson. S. M.: Vaginal hysterectomy: the ideal abortion
in multiparous
patients,
South.
Med.
J. 67:134,
1971.
5. Schulman, H.: Major surgery for abortion and sterilization, Obstet. Gynecol. 40:738, 1972. 6. Priver. D. M.: Abortion-sterilization by abdominal hysterectomy, AM. J. OBSTE:T. GYNECOL. 139:115, 1981. 7. Sloan, D.: Abortion-sterilization by abdominal hysterectomy, AM. J. OBSTET. GYNECOL. 139:116, 1981.
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D. A., Schulz,
K. F., Cates,
Surveillance 1978. W.. Jr.,
and
Tyler,
274
Atrash
et al.
C. W., Jr.: Local tar performing
10. 11.
!L’.
13.
versus general anesthesia: Which is safer suction curettage abortions? AM. J. OBSI’F:T. GYSECOL. 135:1030, 19%. Centers for Disease Control: Surgical Sterilization Surveillance. Tubal Sterikation 1970-1975. issued July, 1979. Center-s f’oor Disease Control: Surgical Sterilization Su-veillance. Hysterectomy in women aged 1.5~+I, 197019i5. issued September, 1980. (Zheng:. If. C. E.. and Rochat, R. \V.: The saf’et!. of cornbined abortion-sterilization procedurw, AM, J, OBSTFX. (~i~xr.c.ar.. 129:.5#. 1977. \\:cil, .-I .: Laparoscopic sterilization with rherapeutic abortion versus sterili;ration ot‘ abortion alone, Obstet. Gynet 01. 52:79, 197x.
14.
Hernandel, I. M., Perry, G., KatL, X. K., and Held. K.: Postabortal laparoscopic tubal sterilization. results in comparison to interval procedures, Obstet. Gvnecol. 50:356. 1977. 15. Haynes. D. M.. Wolfe, W. 41.: ~I’ubal srt:lllv.arion 111 rtl~ indigent population, :%M. ,J. OBSTEI.. GY~ecor.. 106: 10-N. 1970. 16. Muldoon. hl. J.: Gynecological illness ,tt:r,l ~~erdirat~o~l. Br. Med. J, l:A4, 1972. 17. Cares. W., JI-., and Grimes. D.A.: Morbidlt) rind mo]-laji(\ of abortion in the I.‘nited States. i?r Hodgson, J. E., editw : .Ibortion and Sterilization: Medical and Social .A\pec tb, London. 1981, Academic Press, Inc., pp 155 180.