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Therapeutic abortion
Therapeutic A 12 year
review
MANUEL Toronto,
M.
abortion at the Toronto
SPIVAK,
M.D.,
General
Hospital,
1954-l 965
F.R.C.S.(C)
Ontario
The 262 therapeutic abortions carried out at the Toronto General Hospital during the 12 year period (1954 to 1965) are presented. The over-all incidence of therapeutic abortions to deliveries was 1 :I 72, or approximately 5.8 therapeutic abortions for every 1,000 deliveries. The indications for the therapeutic abortions are presented and discussed. The methods used in terminating the pregnancies, along with the subsequent morbidity and complications resulting therefrom, are outlined. The value of the Therapeutic Abortion Committee is discussed, and proposed changes to liberalize existing abortion statutes presented.
H o UG H the subject of therapeutic abortion and its related problems has always been of considerable interest to both the medical and legal professions, it is primarily during the past few years that this topic has received increasing scrutiny by these disciplines. Many legal bodies, both in the United States and Canada, have drafted proposed changes to liberalize existing archaic therapeutic abortion statutes to bring them closer to modern medical and social concepts and principles. It is felt that a liberalized abortion statute, besides making therapeutic abortion voluntary and wholly removed from coercion, should contain the following clauses as reasonable grounds for terminating an existing pregnancy5 : 1. To preserve the life and health of the mother. 2. To permit eugenic indications where there is a likelihood of a child being congenitally abnormal through inheritance or environmental factors.
3. To permit interruption where impregnation was accomplished through sex crime, proved rape, incest, or in the case of a female mentally incapable through youth or mental retardation to anticipate the potential results of coitus. It is obvious that the only way to eliminate criminal abortion is to permit unrestricted legal abortion at the demand of any pregnant woman. Although such a goal would be most desirable, our society at this time would not condone such a radical approach to this problem. Perhaps in time socioeconomic factors will be acceptable grounds for therapeutic abortion in North America, as they are today in the Scandinavian countries. In June of 1963, the Ontario Medical Association formed a Committee on Therapeutic Abortions and Sterilization, with the following objectives: 1. To establish a guide list of indications for therapeutic abortion and sterilization that might be used as a uniform programme in the medical schools of this province. 2. To set up a simple uniform hospital organization for the assessment of these cases. 3. To review the legal aspects involved in carrying out these procedures and, if considered wise, to suggest changes in the statutes or the Ontario Hospital Act. In view of the increasing interest in this
ALT
From the Department of Obstetrics Gynaecology, University of Toronto, Toronto General Hospital.
and
Presented by invitation at the Twenty-second Annual Meeting of the Society of Obstetricians and Gynaecologists of Canada, Jasper, Alberta, june 17-19, 1966.
316
VoluIne Number
97 3
Therapeutic
time, the aim of establishing mittee was not only to prevent use of this procedure, but also abortions which were legally advisable.l?
subject, it was decided to review the cases of therapeutic abortion at the Toronto General Hospital during the 12 year period, 1954 to 1965. In 1964, a Therapeutic Abortion Committee was formed at the Toronto General Hospital, consisting of three members from the Department of Obstetrics and Gynaecolors. All cases thought suitable for therapeutic abortion by members of the staff of the hospital or the Department of Obstetrics and Gynaecology were presented to the Committee with letters from consultants in the various specialties involved. A therapeutic abortion could only be carried out if approved by the Committee. Like many hospitals which have had Therapeutic Abortion Committees for some
Table I. Therapeutic Hospital (1954-1965)
abortions
1 lhzt;;
,,
317
such a Comindiscriminate to provide for and medicaIIy
Incidence In the 12 year period ( 1954-1965) there were 262 therapeutic abortions carried out at the Toronto General Hospital. Of these, 81, approximately 31 per cent, were public cases, and 181, approximately 69 per cent, were private cases (Table I). During this period there were 45,185 deliveries at the hospital. Of these, 14,694 were delivered on the public service, and 30,491 were private deliveries. The over-all inci-
and deliveries,
~ y2zL;
abortion
public
and private,
~~~~~~~C
d;E”e”l;es
Toronto
1
General
dpq;fl;;es
1
&h;~,
1954
11
1955 1956 19.57 1958 1959 1960 1961 1962 1963 1964 1965
16 28 11 25 12 14 25 25 2” 4:; 30
4 1 12 5 6 2 5 9 9 5 10 13
7 15 16 6 19 10 9 16 16 17 33 17
3,724 3,676 3.566 3,597 3,715 3,952 3,908 3,800 3,791 3,769 3,960 3,727
1,192 1,187 1,149 1,241 1,198 1,160 1,184 1,221 1,225 1,280 1,358 1,299
2,532 2,489 2,417 2,356 2,517 2,792 2,724 2,579 2,566 2,489 2,602 2,428
Total
262
81
181
45,185
14.694
30.491
Table II. hospitals
Incidence
of therapeutic
Therapeutic Center
abortions: (
Over-all
abortions
at Toronto
Public
Hospital
and other
Therapeutic 1,000
Deliveries (
General
(
Private
Over-all
)
abortions deliveries Public
per /
Private
Toronto General Hospital, 1954-1965
1:172
1:181
1: 168
5.8
5.5
5.9
New York Mt. Sinai, 1953-1960s
I:175
I:217
1: 159
5.7
4.6
6.3
Beth Israel Hospital, 1956-195811
1:236
4.3
University of Pennsylvania, 1953-19591
1:217
4.6
318
Spivak
February Am. J. Obst.
dence of therapeutic abortions to deliveries was therefore 1:172, or approximately 5.8 therapeutic abortions for every 1,000 deliveries (Table II). On the public service, the incidence was 1: 181, approximately 5.5 therapeutic abortions for every 1,000 deliveries, while on the private service the incidence was 1:168, or approximately 5.9 therapeutic abortions for every 1,000 deliveries. This incidence is very similar to the series from New York Mount Sinai Hospital5 for the years 1953 to 1960, and can be compared to other hospitals and groups in various cities (Table II). In the Scandinavian countries, the incidence is about 45 per 1,000 live births4; in Switzerland about 67 per 1,000
Table III.
Indications of therapeutic abortion Hospital ( 1954-1965)
and numbers at Toronto
live births, live births. therapeutic births. The as a whole live births.5
The various indications for these therapeutic abortions, with the number of cases for each indication, and approximate percentages, are noted in Table III. For the purposes of comparison, the statistics have been grouped so that they may be compared with those reported from New York Mount Sinai3 and the University of Pennsylvania1 (Table IV) . One half of the cases were terminated on psychiatric grounds or for rubella in the first trimester of pregnancy. The over-all incidence of psychiatric indications is approximately 35 per cent; however, during the past 4 years there were 55 out of 120 cases carried out on psychiatric grounds (46 per cent). The incidence of cases interrupted on psychiatric grounds is rising yearly.zp 5 It is interesting to note that 29 patients, approximately 36 per cent of the public cases, and 61, approximately 34 per cent of the private cases, were terminated on psychiatric grounds. These statistics indicate that the same consideration is given to the patient, whether they be public or private. This is in contrast to most series, where there are far more therapeutic abortions carried out on psychiatric grounds on the private patients. Nearly all of the pregnancies terminated
of cases General
Total
34.4 15.6 10.7 7.6 6.2 4.2
9 8 7 6 6 4 3 3 10
3.4 3.1 2.7 2.3 2.3 1.5 1.1 1.1 3.8
262
Table IV. Indications General
90 41 28 20 16 11
Hospital,
New
and in Chile4 about 850 per 1,000 In Japan there are probably more abortions carried out than live current rate in the United States is approximately 2.5 per thousand
Indications
Indications Psychiatric Rubella Cardiovascular disease Renal disease Diseases of nervous system Malignancies Hypertension with previous or present severe toxemia Metabolic endocrine diseases Pregnancy complications Respiratory diseases Tuberculosis Otosclerosis Gastrointestinal diseases Eugenic Others
1, 1967 & Gym.
100
and percentage of cases of therapeutic abortions at Toronto York Mt. Sinai, and University of Pennsylvania Hospitals New York 1953-1960,
Indications Psychiatric Rubella and eugenic Malignancy past or present Cardiovascular Renal Tuberculosis Miscellaneous
Mt. Sinai, 207 cases (%) 42.5 24.6 9.2 7.7 1.4 1.9 12.7
University vania,
of Pennsyl1953-1959, 84 cases f%) 37 22 9 12 4 4 12
Toronto 1954-1965,
General, 262 cases (%I 34.4 16.7 4.2 10.7 7.6 2.3 24.1
Volume Number
97 3
Therapeutic
trends
during
abortions, 4 year periods
Toronto
Changing
I
General
No.
Hospital,
/
7 35
14,563
1954-1965.
1958-1961
%
66
10 14
trends
There has been a definite increase in the number of Therapeutic Abortions at the Toronto General Hospital during each of the three 4 year periods studied in this series. This trend is clearly outlined in Table V. During the 4 year period 1962-1965, there were 44 more therapeutic abortions carried out than during the period 1958-1961, an increase of 58 per cent. Most of this increase was due to the increasing numbers of pregnancies terminated for psychiatric indications, accounting for 30 of the 44 cases. The fluctuation in the rubella incidence is due to the yearly prevalence of this viral infection in the community. In 1954, 1958, and 1962, no pregnancies were terminated for this indication. The range in the other years varied from one case in 1957, to 12 cases in 1964. The large numbers of serious and complex heart disease cases referred to the medical and surgical staffs at the Toronto General Hospital, account for the increase in the number of pregnancies terminated for this indication. Apart from these three indications, nearly the same number of pregnancies were terminated in each 4 year period for all other disorders. During the period 1954-1957, this
1954-1957 Total therapeutic abortions Increase therapeutic abortions Psychiatric Rubella Cardiovascular Others Deliveries
319
However, there were 3 cases terminated solely on this basis, including mothers who had given birth to children suffering from cystic fibrosis, phenylketonuria, and repeated major congenital anomalies in a marriage involving first cousins.
for cardiovascular disease in the mother were cases of chronic rheumatic or congenital heart disease. The history in these cases showed a present or past failure during pregnancy, the lesions being inoperable or requiring openheart surgery. There were 2 cases of coronary artery disease with angina, and a history of previous myocardial infarction. Some of the patients who had abortions subsequently underwent successful cardiac surgery and eventually carried a pregnancy to term uneventfully. Most of the patients with a nervous system disorder had severe and disabling multiple sclerosis. There were a few cases of epilepsy, and one case of Friedrich’s ataxia. The malignancies included 4 cases of carcinoma of the cervix, 5 cases of carcinoma of the breast, and one case each of leukemia and a malignant thymoma. The metabolic and endocrine group of cases were primarily class F diabetes with renal, cardiovascular, and eye complications. There was one case of Addison’s disease, and one case of severe thyrotoxicosis. The pregnancy complications included 5 cases of total placenta previa, and 1 case of severe abruptio placentae in the midtrimester, and one case of a previous uterine rupture repaired per vaginam. The indications under respiratory diseases included severe asthma, bronchiectasis, and pulmonary hypertension. The gastrointestinal disorders were severe ulcerative colitis and regional ileitis. Many cases included under psychiatric grounds had a eugenic consideration as well.
Table V. Therapeutic
abortion
/
No.
I
/
%
76
15 21 11 53
Changing
10
15
25
33
/
1962-1965 No.
1
120 44 55
% 58 46
9
12
18
15
6 36
8 47
15 32
12 27
15,375
15.247
320
February 1, 1967 Am. J. Obst. & Gynec.
Spivak
group accounted for 53 per cent of the cases, and only accounted for 27 per cent of the cases during 1962-1965. During the past 2 years, over 75 per cent of the pregnancies were terminated for three indications : psychiatric, rubella, and cardiovascular disease. Sterilization Of 262 patients, 141 or approximately 54 per cent were sterilized either in addition to the procedure for termination or as a result of the procedure. Of 90 psychiatric cases, 47 or approximately 52 per cent were sterilized, maintaining the same ratio. Nine patients in this series had 2 therapeutic abortions. These patients should likely have been sterilized at the time of the first therapeutic abortion. However, of the 121 patients who were not sterilized in this series, at least 26 of them had one or more full-term normal deliveries subsequently. This is information that has been obtained only from the patient’s chart, and certainly this figure is probably much higher, as many of the patients may have had deliveries in other hospitals in the city, while some patients have only had their therapeutic abortion within the past few years, and have not yet conceived again. Findings
Age. The youngest patient in the group was 15 years old and the oldest was 46 years old. Forty-four per cent were in the 30 to 40 age group; 33 per cent were in the 20 to 30 age group; 17 per cent were over 40 years of age; and 6 per cent were under 20 years of acre. Parity. There were 57 primigravidas in the series. Only 3 patients were greater than para 6. The distribution according to parity was as follows: para 0, 57 patients or 22 per cent; para l-3, 147 patients or 56 per cent; para 4-6, 51 patients or 20 per cent; para 7-12, 3 patients or 1 per cent. The parity of 4 patients or 1 per cent was not recorded. Marital status. Thirty of the patier 11s ’ were _._ single, approximately 12 per cent, 228 were married, and 4 were either divorced, separated, or widowed.
Domicile. One hundred ninety-nine patients lived in Metropolitan Toronto, 63 patients, or approximately 24 per cent, lived in areas outside of Metropolitan Toronto, most from Ontario, but there were a few from outside the Province, and a few from other countries. Duration of gestation. In 145 patients, the duration of gestation was less than 12 weeks; while in 117 patients, the duration of gestation extended from 12 to 26 weeks. Methods of terminating pregnancies. The methods used in terminating these pregnancies are outlined in Table VI. A subtotal hysterectomy was performed in 17 of the 58 abdominal hysterectomies, or approximately 30 per cent, in most cases to speed up the procedure in poor risk patients. Twenty-one of the 66 cases terminated by abdominal hysterotomy were not sterilized. The two Wertheim hysterectomies were performed for Stage I carcinoma of the cervix at approximately 18 weeks’ gestation. The vaginal hysterectomy was performed at 6 weeks’ gestation in a multiparous patient with uterine prolapse afflicted with multiple sclerosis. A noncommunicating horn of a bicornuate uterus containing a pregnancy of approximately 8 to 10 weeks gestation was excised, in a psychiatric patient, after two unsuccessful attempts to terminate this pregnancy by dilatation and curettage. Complications. Twenty-seven patients were classified as morbid, that is with a temperature greater than 100.4’ F. on 2 or more Table VI. Methods
of terminating
pregnancy
No. Method Dilatation Abdominal Abdominal
and curettage hysterotomy hysterectomy
I
of
Per
cent
cases I of caves 98 66 58 (17
37.4 25.2 22.1
31
11.8
2 1
‘0.8 0.4
subtotal)
Fundectomy
Hypertonic
gl~ --.-
c
Wertheim hy! rterectomy hysterectomy Vaginal Excision of noncommunicating horn of bicornuate uterus Total
1 262
0.4 100
Volu1ne Number
97 3
days after operation, an incidence of approximately 10.3 per cent. There were 23 major complications, an incidence of approximately 9 per cent. These included 4 perforations of the uterus; in 3 of these cases, a loop of bowel was brought down or prolapsed at the time of dilatation and curettage, requiring immediate laparotomy and hysterectomy. There were 2 cases of septicemia; 8 cases of hemorrhage in excess of 1,000 C.C. (3 of these latter cases required repeat dilatation and curettages) , and one required a second laparotomy with resuture of the vaginal vault. There were 2 cases of bowel obstruction, one requiring a laparotomy to relieve the obstruction and the other treated successfully conservatively. One patient suffered a pulmonary embolus and severe thrombophlebitis, and improved and survived on anticoagulant therapy. There was one wound dehiscence and 2 extensive wound hematomas. There was one case of urinary tract infection, and one case of pulmonary atelectasis. One patient who had chronic renal disease and hyper,tension, developed a cerebral hernorrhage within the first 24 hours following surgery and died. The mortality rate in this series, therefore, is approximately 0.4 per cent. Comment
Any hospital in which therapeutic abortions are carried out should have a Therapeutic Abortion Committee. Merely having one or two physicians validate a request for a therapeutic abortion is a looti, unreliable method. There is no physician who could not convince one or two of his colleagues of the urgency of any particular situation. An impartial committee is critically urgent for the best interests of the patient and the physician involved, and personalities should not be made a part of the judgment of the existing problem. The letters presented by psychiatrists to the Committee contain much privileged information, and should not be attached to the chart, to be readily available to anyone who may pick it up. It is suggested that these letters be kept in a private file for safe
Therapeutic
abortion
321
keeping, and only a letter stating that the Committee has approved the abortion on psychiatric grounds, be added to the Chart. In hospitals in which therapeutic abortion Committees have been instituted,5> ‘3 I11 I2 there is a tendency to reduce the ratio of therapeutic abortions to live births. At the Toronto General Hospital, a Therapeutic Abortion Committee was instituted in 1964. In contradistinction to other hospitals’ experience, there has been a definite increase in the number of therapeutic abortions carried out since its inception. An obvious reason for this increase is the fact that many of the smaller suburban hospitals hesitate to carry out therapeutic abortions, and prefer to refer these cases for consideration to the Toronto General Hospital, which is the largest teaching hospital at the University of Toronto; especially since it has become known that a Committee to handle these cases now exists. It is felt that a ratio as low as 1:150 deliveries may be justified for teaching institutions, with referred problem cases. The public patients in this series received the same consideration as the private patients, so that the incidence indications, and ratios of therapeutic abortions to deliveries, were practically identical. Despite their rigidities, the statutes have for the most part been liberally interpreted to include not only protection of the mother’s life, but also her health, both physical and mental. However, since it is the obstetricians who violate these laws, it is they perhaps through their National Societies, who should seek their renovation.” Economic and social factors are never in themselves legally and ethically acceptable as justifying therapeutic abortion in this country; yet because of their impact on health and disease, they cannot always be disregarded as secondary factors. Family planning counselling and contraceptive advice and instruction, along with a more liberal attitude toward sterilization, will remove from obstetrical circulation many women who may appear for pregnancy termination at a later date.
322
Spivak
February 1, 1967 Am. J. Obrt. & Gynee.
Patients whose indications for therapeutic abortion are permanent and incurable, should be sterilized. Other patients should be individually considered, and only sterilized if it is in the patient’s best interest. If a hysterotomy is carried out without a sterilization procedure at the same time, a scarred uterus is left which presents obstetric disadvantage in subsequent pregnancies. These particular pregnancies are ideal for termination with injection of hypertonic saline or glucose into the amniotic sac, after removal of about 200 C.C. of amniotic fluid. In 1965, 5 pregnancies in this series were
REFERENCES
1. 2. 3.
4. 5.
6.
Boulas, S. H., Preucel, J. M., and Moore, J. H.: OBST. & GYNEC. 19: 222, 1962. Calderone, M. S.: Abortion in the United States, New York, 1958, Paul B. Hoeber, Inc. Gold, E. M., Erhardt, c. L., Jacobinzer, H., and Nelson. F. G.: Am. Y1. Pub. Health 55: 964, 1965. ’ Greenhill, J. P.: Clin. Obst. & Gynec. 7: 37, 1964. Guttmacher, A. F.: In Meigs, J. V., and Sturgis, S. H., editors: Progress in Gynaecology, New York, 1963, Grune & Stratton, Inc., vol. IV.
Discussion DR. VANT,
7. 8. 9. 10. 11.
Hall, R. E.: AM. J. OBST. & GYNEC. 91: 518, 1965. Jeffcoate, T. N. A.: Brit. M. J. 1: 5173, 1960. Lederman, J, J.: Canad. M. A. J. 87: 2 16, 1962. Overstreet, E. W.: Clin. O&t. & Gynec. 7: 1, 1964. Russell, K. P.: Clin. Obst. & Gynec. 1: 967, 1958. Save& L. E., and Perlmutter, I. K.: AM. J. OBST. & GYNEC. 80: 1192, 1960. 1849 Yonge Street Toronto 7, Ontario
recent 10 year study that the incidence
Edmonton, Alberta. As I open the discussion of this paper I can’t help but feel that the absolute indications for therapeutic abortion are decreasing each year and that the increase in abortions for psychiatric reasons noted in recent years by Dr. Spivak is but a reflection of the socioeconomic tensions engendered by our modern way of life. Most hospitals should have a therapeutic abor-
tion and sterilization
terminated satisfactorily by this method without complication. Therapeutic abortion at any stage of gestation is still a somewhat hazardous procedure and should be recognized as such. It is not just a dilatation and curettage, as some members of the profession still think. It is most difficult, especially in a primigravida, to dilate the cervix sufficiently to remove the products of conception without either tearing or injuring the cervix. Perforations still occur, in spite of skill and care. However, as in any operative procedure, the complications can be accepted if the indications are valid.
committee.
General
rules of
procedure are necessary to enable a panel of three representative members of that committee, picked for each problem presented, to review the evidence and by majority vote to assent or dissent to the application. In that manner the doctor will be spared the onus of the final decision, the hospital will be protected, and the legal requirements will be satisfied. The incidence of 5.8 therapeutic abortions for each 1,000 deliveries seems reasonable and reflects the fact that the Toronto General Hospital acts as a center. Lohnerl of Utah noted in a
of thera-
peutic abortions in Salt Lake City was one in every 2,482 deliveries. He compared this to an incidence of 1:160 over a 5 year period at Mt. Sinai in New York and to 1:6,416 over a 10 year period, including 102,654 deliveries, at the Los Angeles County Hospital. He concluded that the
various figures reflect the thinking
of the region.
Our figures at the University Hospital in Edmonton through the years 1955-1965 inclusive reveal an incidence of 1.03 therapeutic abortion to each 1,000 deliveries (33 in 22,292 deliveries). Thirteeen of these were performed for psychiatric reasons and all but one of these had tubal ligation as well. Seventeen pregnancies were interrupted because of a variety of medical reasons and all but two patients had abdominal incision and tubal ligation. Three women who contracted rubella during the first 6 weeks of pregnancy were aborted by dilatation and curettage. During the years 1962-1965 inclusive of 16 aborted pregnancies 7 were for psychiatric reasons, 6 for medical problems, and 3 because of rubella.
review
MANUEL Toronto,
M.
abortion at the Toronto
SPIVAK,
M.D.,
General
Hospital,
1954-l 965
F.R.C.S.(C)
Ontario
The 262 therapeutic abortions carried out at the Toronto General Hospital during the 12 year period (1954 to 1965) are presented. The over-all incidence of therapeutic abortions to deliveries was 1 :I 72, or approximately 5.8 therapeutic abortions for every 1,000 deliveries. The indications for the therapeutic abortions are presented and discussed. The methods used in terminating the pregnancies, along with the subsequent morbidity and complications resulting therefrom, are outlined. The value of the Therapeutic Abortion Committee is discussed, and proposed changes to liberalize existing abortion statutes presented.
H o UG H the subject of therapeutic abortion and its related problems has always been of considerable interest to both the medical and legal professions, it is primarily during the past few years that this topic has received increasing scrutiny by these disciplines. Many legal bodies, both in the United States and Canada, have drafted proposed changes to liberalize existing archaic therapeutic abortion statutes to bring them closer to modern medical and social concepts and principles. It is felt that a liberalized abortion statute, besides making therapeutic abortion voluntary and wholly removed from coercion, should contain the following clauses as reasonable grounds for terminating an existing pregnancy5 : 1. To preserve the life and health of the mother. 2. To permit eugenic indications where there is a likelihood of a child being congenitally abnormal through inheritance or environmental factors.
3. To permit interruption where impregnation was accomplished through sex crime, proved rape, incest, or in the case of a female mentally incapable through youth or mental retardation to anticipate the potential results of coitus. It is obvious that the only way to eliminate criminal abortion is to permit unrestricted legal abortion at the demand of any pregnant woman. Although such a goal would be most desirable, our society at this time would not condone such a radical approach to this problem. Perhaps in time socioeconomic factors will be acceptable grounds for therapeutic abortion in North America, as they are today in the Scandinavian countries. In June of 1963, the Ontario Medical Association formed a Committee on Therapeutic Abortions and Sterilization, with the following objectives: 1. To establish a guide list of indications for therapeutic abortion and sterilization that might be used as a uniform programme in the medical schools of this province. 2. To set up a simple uniform hospital organization for the assessment of these cases. 3. To review the legal aspects involved in carrying out these procedures and, if considered wise, to suggest changes in the statutes or the Ontario Hospital Act. In view of the increasing interest in this
ALT
From the Department of Obstetrics Gynaecology, University of Toronto, Toronto General Hospital.
and
Presented by invitation at the Twenty-second Annual Meeting of the Society of Obstetricians and Gynaecologists of Canada, Jasper, Alberta, june 17-19, 1966.
316
VoluIne Number
97 3
Therapeutic
time, the aim of establishing mittee was not only to prevent use of this procedure, but also abortions which were legally advisable.l?
subject, it was decided to review the cases of therapeutic abortion at the Toronto General Hospital during the 12 year period, 1954 to 1965. In 1964, a Therapeutic Abortion Committee was formed at the Toronto General Hospital, consisting of three members from the Department of Obstetrics and Gynaecolors. All cases thought suitable for therapeutic abortion by members of the staff of the hospital or the Department of Obstetrics and Gynaecology were presented to the Committee with letters from consultants in the various specialties involved. A therapeutic abortion could only be carried out if approved by the Committee. Like many hospitals which have had Therapeutic Abortion Committees for some
Table I. Therapeutic Hospital (1954-1965)
abortions
1 lhzt;;
,,
317
such a Comindiscriminate to provide for and medicaIIy
Incidence In the 12 year period ( 1954-1965) there were 262 therapeutic abortions carried out at the Toronto General Hospital. Of these, 81, approximately 31 per cent, were public cases, and 181, approximately 69 per cent, were private cases (Table I). During this period there were 45,185 deliveries at the hospital. Of these, 14,694 were delivered on the public service, and 30,491 were private deliveries. The over-all inci-
and deliveries,
~ y2zL;
abortion
public
and private,
~~~~~~~C
d;E”e”l;es
Toronto
1
General
dpq;fl;;es
1
&h;~,
1954
11
1955 1956 19.57 1958 1959 1960 1961 1962 1963 1964 1965
16 28 11 25 12 14 25 25 2” 4:; 30
4 1 12 5 6 2 5 9 9 5 10 13
7 15 16 6 19 10 9 16 16 17 33 17
3,724 3,676 3.566 3,597 3,715 3,952 3,908 3,800 3,791 3,769 3,960 3,727
1,192 1,187 1,149 1,241 1,198 1,160 1,184 1,221 1,225 1,280 1,358 1,299
2,532 2,489 2,417 2,356 2,517 2,792 2,724 2,579 2,566 2,489 2,602 2,428
Total
262
81
181
45,185
14.694
30.491
Table II. hospitals
Incidence
of therapeutic
Therapeutic Center
abortions: (
Over-all
abortions
at Toronto
Public
Hospital
and other
Therapeutic 1,000
Deliveries (
General
(
Private
Over-all
)
abortions deliveries Public
per /
Private
Toronto General Hospital, 1954-1965
1:172
1:181
1: 168
5.8
5.5
5.9
New York Mt. Sinai, 1953-1960s
I:175
I:217
1: 159
5.7
4.6
6.3
Beth Israel Hospital, 1956-195811
1:236
4.3
University of Pennsylvania, 1953-19591
1:217
4.6
318
Spivak
February Am. J. Obst.
dence of therapeutic abortions to deliveries was therefore 1:172, or approximately 5.8 therapeutic abortions for every 1,000 deliveries (Table II). On the public service, the incidence was 1: 181, approximately 5.5 therapeutic abortions for every 1,000 deliveries, while on the private service the incidence was 1:168, or approximately 5.9 therapeutic abortions for every 1,000 deliveries. This incidence is very similar to the series from New York Mount Sinai Hospital5 for the years 1953 to 1960, and can be compared to other hospitals and groups in various cities (Table II). In the Scandinavian countries, the incidence is about 45 per 1,000 live births4; in Switzerland about 67 per 1,000
Table III.
Indications of therapeutic abortion Hospital ( 1954-1965)
and numbers at Toronto
live births, live births. therapeutic births. The as a whole live births.5
The various indications for these therapeutic abortions, with the number of cases for each indication, and approximate percentages, are noted in Table III. For the purposes of comparison, the statistics have been grouped so that they may be compared with those reported from New York Mount Sinai3 and the University of Pennsylvania1 (Table IV) . One half of the cases were terminated on psychiatric grounds or for rubella in the first trimester of pregnancy. The over-all incidence of psychiatric indications is approximately 35 per cent; however, during the past 4 years there were 55 out of 120 cases carried out on psychiatric grounds (46 per cent). The incidence of cases interrupted on psychiatric grounds is rising yearly.zp 5 It is interesting to note that 29 patients, approximately 36 per cent of the public cases, and 61, approximately 34 per cent of the private cases, were terminated on psychiatric grounds. These statistics indicate that the same consideration is given to the patient, whether they be public or private. This is in contrast to most series, where there are far more therapeutic abortions carried out on psychiatric grounds on the private patients. Nearly all of the pregnancies terminated
of cases General
Total
34.4 15.6 10.7 7.6 6.2 4.2
9 8 7 6 6 4 3 3 10
3.4 3.1 2.7 2.3 2.3 1.5 1.1 1.1 3.8
262
Table IV. Indications General
90 41 28 20 16 11
Hospital,
New
and in Chile4 about 850 per 1,000 In Japan there are probably more abortions carried out than live current rate in the United States is approximately 2.5 per thousand
Indications
Indications Psychiatric Rubella Cardiovascular disease Renal disease Diseases of nervous system Malignancies Hypertension with previous or present severe toxemia Metabolic endocrine diseases Pregnancy complications Respiratory diseases Tuberculosis Otosclerosis Gastrointestinal diseases Eugenic Others
1, 1967 & Gym.
100
and percentage of cases of therapeutic abortions at Toronto York Mt. Sinai, and University of Pennsylvania Hospitals New York 1953-1960,
Indications Psychiatric Rubella and eugenic Malignancy past or present Cardiovascular Renal Tuberculosis Miscellaneous
Mt. Sinai, 207 cases (%) 42.5 24.6 9.2 7.7 1.4 1.9 12.7
University vania,
of Pennsyl1953-1959, 84 cases f%) 37 22 9 12 4 4 12
Toronto 1954-1965,
General, 262 cases (%I 34.4 16.7 4.2 10.7 7.6 2.3 24.1
Volume Number
97 3
Therapeutic
trends
during
abortions, 4 year periods
Toronto
Changing
I
General
No.
Hospital,
/
7 35
14,563
1954-1965.
1958-1961
%
66
10 14
trends
There has been a definite increase in the number of Therapeutic Abortions at the Toronto General Hospital during each of the three 4 year periods studied in this series. This trend is clearly outlined in Table V. During the 4 year period 1962-1965, there were 44 more therapeutic abortions carried out than during the period 1958-1961, an increase of 58 per cent. Most of this increase was due to the increasing numbers of pregnancies terminated for psychiatric indications, accounting for 30 of the 44 cases. The fluctuation in the rubella incidence is due to the yearly prevalence of this viral infection in the community. In 1954, 1958, and 1962, no pregnancies were terminated for this indication. The range in the other years varied from one case in 1957, to 12 cases in 1964. The large numbers of serious and complex heart disease cases referred to the medical and surgical staffs at the Toronto General Hospital, account for the increase in the number of pregnancies terminated for this indication. Apart from these three indications, nearly the same number of pregnancies were terminated in each 4 year period for all other disorders. During the period 1954-1957, this
1954-1957 Total therapeutic abortions Increase therapeutic abortions Psychiatric Rubella Cardiovascular Others Deliveries
319
However, there were 3 cases terminated solely on this basis, including mothers who had given birth to children suffering from cystic fibrosis, phenylketonuria, and repeated major congenital anomalies in a marriage involving first cousins.
for cardiovascular disease in the mother were cases of chronic rheumatic or congenital heart disease. The history in these cases showed a present or past failure during pregnancy, the lesions being inoperable or requiring openheart surgery. There were 2 cases of coronary artery disease with angina, and a history of previous myocardial infarction. Some of the patients who had abortions subsequently underwent successful cardiac surgery and eventually carried a pregnancy to term uneventfully. Most of the patients with a nervous system disorder had severe and disabling multiple sclerosis. There were a few cases of epilepsy, and one case of Friedrich’s ataxia. The malignancies included 4 cases of carcinoma of the cervix, 5 cases of carcinoma of the breast, and one case each of leukemia and a malignant thymoma. The metabolic and endocrine group of cases were primarily class F diabetes with renal, cardiovascular, and eye complications. There was one case of Addison’s disease, and one case of severe thyrotoxicosis. The pregnancy complications included 5 cases of total placenta previa, and 1 case of severe abruptio placentae in the midtrimester, and one case of a previous uterine rupture repaired per vaginam. The indications under respiratory diseases included severe asthma, bronchiectasis, and pulmonary hypertension. The gastrointestinal disorders were severe ulcerative colitis and regional ileitis. Many cases included under psychiatric grounds had a eugenic consideration as well.
Table V. Therapeutic
abortion
/
No.
I
/
%
76
15 21 11 53
Changing
10
15
25
33
/
1962-1965 No.
1
120 44 55
% 58 46
9
12
18
15
6 36
8 47
15 32
12 27
15,375
15.247
320
February 1, 1967 Am. J. Obst. & Gynec.
Spivak
group accounted for 53 per cent of the cases, and only accounted for 27 per cent of the cases during 1962-1965. During the past 2 years, over 75 per cent of the pregnancies were terminated for three indications : psychiatric, rubella, and cardiovascular disease. Sterilization Of 262 patients, 141 or approximately 54 per cent were sterilized either in addition to the procedure for termination or as a result of the procedure. Of 90 psychiatric cases, 47 or approximately 52 per cent were sterilized, maintaining the same ratio. Nine patients in this series had 2 therapeutic abortions. These patients should likely have been sterilized at the time of the first therapeutic abortion. However, of the 121 patients who were not sterilized in this series, at least 26 of them had one or more full-term normal deliveries subsequently. This is information that has been obtained only from the patient’s chart, and certainly this figure is probably much higher, as many of the patients may have had deliveries in other hospitals in the city, while some patients have only had their therapeutic abortion within the past few years, and have not yet conceived again. Findings
Age. The youngest patient in the group was 15 years old and the oldest was 46 years old. Forty-four per cent were in the 30 to 40 age group; 33 per cent were in the 20 to 30 age group; 17 per cent were over 40 years of age; and 6 per cent were under 20 years of acre. Parity. There were 57 primigravidas in the series. Only 3 patients were greater than para 6. The distribution according to parity was as follows: para 0, 57 patients or 22 per cent; para l-3, 147 patients or 56 per cent; para 4-6, 51 patients or 20 per cent; para 7-12, 3 patients or 1 per cent. The parity of 4 patients or 1 per cent was not recorded. Marital status. Thirty of the patier 11s ’ were _._ single, approximately 12 per cent, 228 were married, and 4 were either divorced, separated, or widowed.
Domicile. One hundred ninety-nine patients lived in Metropolitan Toronto, 63 patients, or approximately 24 per cent, lived in areas outside of Metropolitan Toronto, most from Ontario, but there were a few from outside the Province, and a few from other countries. Duration of gestation. In 145 patients, the duration of gestation was less than 12 weeks; while in 117 patients, the duration of gestation extended from 12 to 26 weeks. Methods of terminating pregnancies. The methods used in terminating these pregnancies are outlined in Table VI. A subtotal hysterectomy was performed in 17 of the 58 abdominal hysterectomies, or approximately 30 per cent, in most cases to speed up the procedure in poor risk patients. Twenty-one of the 66 cases terminated by abdominal hysterotomy were not sterilized. The two Wertheim hysterectomies were performed for Stage I carcinoma of the cervix at approximately 18 weeks’ gestation. The vaginal hysterectomy was performed at 6 weeks’ gestation in a multiparous patient with uterine prolapse afflicted with multiple sclerosis. A noncommunicating horn of a bicornuate uterus containing a pregnancy of approximately 8 to 10 weeks gestation was excised, in a psychiatric patient, after two unsuccessful attempts to terminate this pregnancy by dilatation and curettage. Complications. Twenty-seven patients were classified as morbid, that is with a temperature greater than 100.4’ F. on 2 or more Table VI. Methods
of terminating
pregnancy
No. Method Dilatation Abdominal Abdominal
and curettage hysterotomy hysterectomy
I
of
Per
cent
cases I of caves 98 66 58 (17
37.4 25.2 22.1
31
11.8
2 1
‘0.8 0.4
subtotal)
Fundectomy
Hypertonic
gl~ --.-
c
Wertheim hy! rterectomy hysterectomy Vaginal Excision of noncommunicating horn of bicornuate uterus Total
1 262
0.4 100
Volu1ne Number
97 3
days after operation, an incidence of approximately 10.3 per cent. There were 23 major complications, an incidence of approximately 9 per cent. These included 4 perforations of the uterus; in 3 of these cases, a loop of bowel was brought down or prolapsed at the time of dilatation and curettage, requiring immediate laparotomy and hysterectomy. There were 2 cases of septicemia; 8 cases of hemorrhage in excess of 1,000 C.C. (3 of these latter cases required repeat dilatation and curettages) , and one required a second laparotomy with resuture of the vaginal vault. There were 2 cases of bowel obstruction, one requiring a laparotomy to relieve the obstruction and the other treated successfully conservatively. One patient suffered a pulmonary embolus and severe thrombophlebitis, and improved and survived on anticoagulant therapy. There was one wound dehiscence and 2 extensive wound hematomas. There was one case of urinary tract infection, and one case of pulmonary atelectasis. One patient who had chronic renal disease and hyper,tension, developed a cerebral hernorrhage within the first 24 hours following surgery and died. The mortality rate in this series, therefore, is approximately 0.4 per cent. Comment
Any hospital in which therapeutic abortions are carried out should have a Therapeutic Abortion Committee. Merely having one or two physicians validate a request for a therapeutic abortion is a looti, unreliable method. There is no physician who could not convince one or two of his colleagues of the urgency of any particular situation. An impartial committee is critically urgent for the best interests of the patient and the physician involved, and personalities should not be made a part of the judgment of the existing problem. The letters presented by psychiatrists to the Committee contain much privileged information, and should not be attached to the chart, to be readily available to anyone who may pick it up. It is suggested that these letters be kept in a private file for safe
Therapeutic
abortion
321
keeping, and only a letter stating that the Committee has approved the abortion on psychiatric grounds, be added to the Chart. In hospitals in which therapeutic abortion Committees have been instituted,5> ‘3 I11 I2 there is a tendency to reduce the ratio of therapeutic abortions to live births. At the Toronto General Hospital, a Therapeutic Abortion Committee was instituted in 1964. In contradistinction to other hospitals’ experience, there has been a definite increase in the number of therapeutic abortions carried out since its inception. An obvious reason for this increase is the fact that many of the smaller suburban hospitals hesitate to carry out therapeutic abortions, and prefer to refer these cases for consideration to the Toronto General Hospital, which is the largest teaching hospital at the University of Toronto; especially since it has become known that a Committee to handle these cases now exists. It is felt that a ratio as low as 1:150 deliveries may be justified for teaching institutions, with referred problem cases. The public patients in this series received the same consideration as the private patients, so that the incidence indications, and ratios of therapeutic abortions to deliveries, were practically identical. Despite their rigidities, the statutes have for the most part been liberally interpreted to include not only protection of the mother’s life, but also her health, both physical and mental. However, since it is the obstetricians who violate these laws, it is they perhaps through their National Societies, who should seek their renovation.” Economic and social factors are never in themselves legally and ethically acceptable as justifying therapeutic abortion in this country; yet because of their impact on health and disease, they cannot always be disregarded as secondary factors. Family planning counselling and contraceptive advice and instruction, along with a more liberal attitude toward sterilization, will remove from obstetrical circulation many women who may appear for pregnancy termination at a later date.
322
Spivak
February 1, 1967 Am. J. Obrt. & Gynee.
Patients whose indications for therapeutic abortion are permanent and incurable, should be sterilized. Other patients should be individually considered, and only sterilized if it is in the patient’s best interest. If a hysterotomy is carried out without a sterilization procedure at the same time, a scarred uterus is left which presents obstetric disadvantage in subsequent pregnancies. These particular pregnancies are ideal for termination with injection of hypertonic saline or glucose into the amniotic sac, after removal of about 200 C.C. of amniotic fluid. In 1965, 5 pregnancies in this series were
REFERENCES
1. 2. 3.
4. 5.
6.
Boulas, S. H., Preucel, J. M., and Moore, J. H.: OBST. & GYNEC. 19: 222, 1962. Calderone, M. S.: Abortion in the United States, New York, 1958, Paul B. Hoeber, Inc. Gold, E. M., Erhardt, c. L., Jacobinzer, H., and Nelson. F. G.: Am. Y1. Pub. Health 55: 964, 1965. ’ Greenhill, J. P.: Clin. Obst. & Gynec. 7: 37, 1964. Guttmacher, A. F.: In Meigs, J. V., and Sturgis, S. H., editors: Progress in Gynaecology, New York, 1963, Grune & Stratton, Inc., vol. IV.
Discussion DR. VANT,
7. 8. 9. 10. 11.
Hall, R. E.: AM. J. OBST. & GYNEC. 91: 518, 1965. Jeffcoate, T. N. A.: Brit. M. J. 1: 5173, 1960. Lederman, J, J.: Canad. M. A. J. 87: 2 16, 1962. Overstreet, E. W.: Clin. O&t. & Gynec. 7: 1, 1964. Russell, K. P.: Clin. Obst. & Gynec. 1: 967, 1958. Save& L. E., and Perlmutter, I. K.: AM. J. OBST. & GYNEC. 80: 1192, 1960. 1849 Yonge Street Toronto 7, Ontario
recent 10 year study that the incidence
Edmonton, Alberta. As I open the discussion of this paper I can’t help but feel that the absolute indications for therapeutic abortion are decreasing each year and that the increase in abortions for psychiatric reasons noted in recent years by Dr. Spivak is but a reflection of the socioeconomic tensions engendered by our modern way of life. Most hospitals should have a therapeutic abor-
tion and sterilization
terminated satisfactorily by this method without complication. Therapeutic abortion at any stage of gestation is still a somewhat hazardous procedure and should be recognized as such. It is not just a dilatation and curettage, as some members of the profession still think. It is most difficult, especially in a primigravida, to dilate the cervix sufficiently to remove the products of conception without either tearing or injuring the cervix. Perforations still occur, in spite of skill and care. However, as in any operative procedure, the complications can be accepted if the indications are valid.
committee.
General
rules of
procedure are necessary to enable a panel of three representative members of that committee, picked for each problem presented, to review the evidence and by majority vote to assent or dissent to the application. In that manner the doctor will be spared the onus of the final decision, the hospital will be protected, and the legal requirements will be satisfied. The incidence of 5.8 therapeutic abortions for each 1,000 deliveries seems reasonable and reflects the fact that the Toronto General Hospital acts as a center. Lohnerl of Utah noted in a
of thera-
peutic abortions in Salt Lake City was one in every 2,482 deliveries. He compared this to an incidence of 1:160 over a 5 year period at Mt. Sinai in New York and to 1:6,416 over a 10 year period, including 102,654 deliveries, at the Los Angeles County Hospital. He concluded that the
various figures reflect the thinking
of the region.
Our figures at the University Hospital in Edmonton through the years 1955-1965 inclusive reveal an incidence of 1.03 therapeutic abortion to each 1,000 deliveries (33 in 22,292 deliveries). Thirteeen of these were performed for psychiatric reasons and all but one of these had tubal ligation as well. Seventeen pregnancies were interrupted because of a variety of medical reasons and all but two patients had abdominal incision and tubal ligation. Three women who contracted rubella during the first 6 weeks of pregnancy were aborted by dilatation and curettage. During the years 1962-1965 inclusive of 16 aborted pregnancies 7 were for psychiatric reasons, 6 for medical problems, and 3 because of rubella.