David A. Grimes

Diagnostic dilation and curettage: A reappraisal

Diagnostic dilation and curettage (D & C) is widely considered to be the method of choice for obtaining samples of endometrium for histologic examination, although the scientific basis for this assumption is elusive. Despite extensive use of D & C, the tissue yield and diagnostic accuracy of this technique have not been adequately evaluated. More is known about these features of a newer diagnostic procedure, Vabra aspiration (VA). VA also appears to be safer, less expensive, and more convenient than D & C. Until the alleged benefits of diagnostic D & C can be shown to outweigh its risks and costs (approaching one billion dollars per year in the United States alone), D & C probably should not be the primary procedure used for obtaining most samples of endometrium.

Epidemiology of gestational trophoblastic disease

The epidemiology of gestational trophoblastic disease is not well understood. Methodologic problems with published reports limit the interpretation of incidence data, although the frequency of hydatidiform mole appears to be about one per 1000 pregnancies. No consistent temporal trends in rates of either hydatidiform mole or choriocarcinoma are evident. Hydatidiform mole appears to be caused by abnormal gametogenesis and fertilization. Age, ethnicity, and a history of hydatidiform mole appear to be important risk factors for hydatidiform mole. Age, ethnicity, a history of hydatidiform mole or fetal wastage, and ABO blood group interactions appear to be important risk factors for choriocarcinoma. Future studies should focus on the mechanisms by which these risk factors influence gametogenesis, fertilization, and malignant transformation of trophoblastic tissue.

Prophylactic antibiotics for curettage abortion

Opinion is divided as to the advisability of routine use of prophylactic antibiotics for curettage abortion. Six studies, including three randomized clinical trials, suggest that prophylaxis reduces infectious morbidity associated with curettage abortions by about one half. Three other studies, two involving prophylaxis for instillation abortions and one involving a vaginal antiseptic for curettage abortion, support the hypothesis that antimicrobial prophylaxis reduces morbidity. Tetracyclines are commonly used for this purpose. The cost of routine prophylaxis even with an expensive tetracycline would appear to be offset by the savings in direct and indirect costs. Prophylaxis may help prevent both short-term morbidity and potential late sequelae, such as ectopic pregnancy and infertility.

Fatal amniotic fluid embolism during legally induced abortion, United States, 1972 to 1978

Amniotic fluid embolism (AFE) has emerged as an important cause of death from legally induced abortion. In the period 1972-1978, 12 probably and three autopsy-confirmed cases of fatal AFE during legally induced abortion were identified in the United States (12% of all deaths from legal abortion). Fourteen deaths from AFE were associated with labor-inducing techniques, and one with hysterotomy. The risk of death appears to be related to gestational age: the death-to-case rate for AFE increases progressively from nil at less than or equal to 12 weeks gestation to 7.2 deaths per 100,000 abortions at greater than or equal to 21 weeks gestation. Because treatment is frequently ineffective, prevention of AFE is critical. Performing abortions early in pregnancy and using curettage techniques whenever feasible should reduce the risk of death from this obstetric accident during legally induced abortion.

Preventing febrile complications of suction curettage abortion.

To identify risk factors for febrile complications after suction curettage abortion, we analyzed the data of 26,332 women who underwent suction curettage abortion at five participating centers in the Joint Program for the Study of Abortion, Part III, from 1975 to 1978. We defined febrile morbidity as an oral temperature of greater than or equal to 38 degrees C for 2 days or longer. The febrile morbidity rate was 0.34 per 100 abortions. We performed a multivariate analysis using a linear logistic regression model. Prophylactic antibiotics proved to be the most protective factor, reducing the rate of febrile complications to about one third that of women who received no prophylactic antibiotics (relative risk 0.36; 95% confidence interval 0.18 to 0.70). Patients who had had one or more previous births also had a significantly lower risk of febrile morbidity (relative risk 0.54; 95% confidence interval 0.33 to 0.88). Other factors did not significantly affect the febrile complication rate.

Morbidity and mortality of abortion in the United States

Publisher Summary This chapter discusses the morbidity and mortality of abortion in the United States. Legally induced abortion is a remarkably safe surgical procedure, whether compared to other commonly performed types of surgeries or to the alternative for pregnant women of carrying the pregnancy to term. Unfortunately, the relative safety of legally induced abortion is not widely appreciated throughout the world, possibly because of the stigma attached to abortion in countries where it is still illegal. Moreover, even in some countries where it has been legalized, surgical techniques are being used that may heighten rather than reduce the potential for complications and deaths. An important technical factor affecting the results of any surgical procedure, including induced abortion, is the skill of the operator. Unfortunately, valid criteria to measure an operators skill have not been resolved by the different studies of abortion morbidity. The most important non-technical risk factor is gestational age.

Sterilization-attributable deaths in Bangladesh

From January 1, 1979, to March 31, 1980, 20 sterilization‐attributable deaths were identified in Dacca and Rajshahi Divisions, Bangladesh. The leading cause of death from tubectomy was anesthesia overdose and from vasectomy, scrotal infection. Overall, the sterilization‐attributable death‐to‐case rate was 21.3 deaths/100,000 procedures. The health impact of contraceptive sterilization is highly favorable: for each 100,000 tubectomies performed, the cost in lives (19) is offset by approximately 1015 maternal deaths averted.

Rh immunoglobulin utilization after ectopic pregnancy

To assess the use of Rh immunoglobulin (RhIG) after ectopic pregnancy, we reviewed the charts of 305 patients treated from 1975 through 1978 at a large metropolitan hospital. We compared these patients with 389 who had had spontaneous abortions and been treated at the same hospital in 1975. The rate of ascertainment of Rh type was significantly higher for the group with ectopic pregnancy than for the group with spontaneous abortion (98.4% versus 95.1%; p less than 0.05). Nevertheless, presumable fertile RhIG candidates after ectopic pregnancy were 3.3 times more likely not to receive RhIG than candidates after spontaneous abortion (64.3% versus 19.4%;; p less than 0.01). Patients with ectopic pregnancy are an important part of the RhIG utilization gap; the mechanism for providing prophylaxis for patients needs to be improved.

Dilatation and Evacuation

Three general approaches exist for emptying the uterus during the second trimester of pregnancy: hysterotomy, induction of labor, and dilatation and evacuation (D&E). Each of these methods of abortion shares two features: 1) a portal of exit, and 2) expulsive or tractile force on extraction to evacuate the uterine contents.