The effectiveness of locally applied ethanol in terminating pregnancy in cynomolgus monkeys is described, and initial results of the Food and Drug Administration approved phase 1 studies in humans are presented. Following intrauterine injection of 70% ethanol in cynomolgus monkeys, there appeared to be immediate necrosis of the superficial endometrium in regions that are covered by placenta. The damage was observed in all regions of the uterus whether the injection site was at the fundal or cervical end of the uterus. This indicates that the ethanol spreads between the fetal membranes and the endometrium for the entire length of the endometrial cavity. Some placental necrosis was seen but the damage did not appear to be as extensive as that noted in the endometrium. No histologic damage was observed in either the tubes or ovaries of the 3 monkeys who were subjected to hysterectomy and salpingo-oophorectomy. The endometrial damage appeared to be reversible. Intrauterine instillation of 2 ml 35% or 70% ethanol appeared to be well tolerated in nonpregnant human subjects. Subsequent histologic evaluation showed superficial necrosis of the endometrium between 1 and 24 hours following injections. Similar laboratory studies, in which intrauterine 70% ethanol was administered to nonpregnant rhesus monkeys, showed repair of endometrial tissue beginning at 1 week, with normal endometrium observed 1 month after alcohol injection. The findings suggest that menstrual regulation might be effected by a simple intrauterine injection of ethanol.
Abortion experiences among New Zealand women.
The incidence of abortion among New Zealand women was surveyed in May 1976 over a national random probability sample of 1200 women aged 15 years and over. Of the 978 respondents who had been pregnant, 164 (16.8%) had at some stage considered terminating their pregnancy. 1/3 of them subsequently tried to obtain an abortion with 84% success. Single women and/or women in the 15-25 year age group were more likely than married or older women to have considered abortion when pregnant and were more likely to have followed through with an abortion attempt after considereing abortion. Before 1974, 62% of the abortion attempts involved an unqualified operator, in contrast to only 5% of those attempted or obtained from 1974-1976. There was no significant difference among religious groups in their rates of abortion attempts, but 82% of Catholic women were single at the time of their atttempt by comparison with 53% of all other respondents. Prior to their abortion experiences, the abortion group showed a much lower incidence of contraception (52%) than 71% for the control group. They also used a greater proportion of inadequate methods than did the control group. There was a clear shift to more reliable methods and greater frequency of contraception subsequent to abortion experiences, giving the post-abortion group a pattern of usage that did not differ significantly from that of the control group.
An evaluation of the counselling given to patients having a therapeutic abortion.
A questionnaire was devised in the attempt to assess patient reactions to abortion counseling experiences. Patients' reactions were documented in relation to various aspects of counseling, including explanation of the abortion process, perceived characteristics of the counselor, and the continuing availability of the counselor both throughout the abortion process and after discharge. The attempt was also made to assess patients' reactions to the atmosphere and medical and nursing staff of the Auckland Medical Aid Trust Hospital, New Zealand. All but 6 of the 293 patients who had an abortion under local anesthesia during October 1977 completed the questionnaire. Ethnic origin but not education appeared to be related to the successful reduction of anxiety by the provision of information and supportive counseling. Independent of this relationship, patients, who did not practice a religion were more likely to have their anxiety reduced by counseling. In general, the younger the patient the more likely she was to report that counseling was desirable, and unmarried women were also more likely than married women to indicate that counseling was necessary. Patients who judged that they would require further counseling were more likely to be both non-European and of limited education. The fact that 83% of the patients using the specialist abortion service at the Auckland hospital considered counseling to be necessary in their case suggests that there is sufficient demand to have counseling available in any future abortion facility.
Abortion (Amendment) Bill. [Letter]
Mr. Corrie's argument for the Abortion (Amendment) Bill is based on a misunderstanding of the problem. All evidence supports the conclusion that is is impossible to prevent abortion by legislation. It was a recognition of this fact which persuaded many people of the necessity for a liberal Act in 1967. Since that time nothing has changed to alter the supposition that a large proportion of women denied legal abortion will seek an illegal abortion. The major medical establishment bodies recognize and accept this and are opposed to the Corrie Bill. Those who work in this area know that what is needed is a much greater effort in providing sex education and access to contraceptive advice and methods for those with special problems. 1 of the ironies of the proposed legislation is that abortion rates have until very recently been declining, following the major expansion of family planning provision in 1974. The attempt to lower the accepted limit for abortion to 20 weeks would only add to the anguish and problems of women and doctors in the very small proportion of cases involved, and it is difficult to see why the Lane Committee recommendation of 24 weeks cannot be accepted as a compromise. Of the 3 principle changes introduced in the Bill, it is the 1 which aims to separate counseling from operating which has the most important consequences. This measure is aimed at the 2 primary abortion charities which were established to meet the deficiencies of provision by the National Health Service. Between them they account for 30-40% of the abortions performed. There is no evidence for the suggestion that people working for these charities have a financial interest in drumming up work.
Endometriosis among the Hausa/Fulani population of Nigeria.
Endometriosis is said to be rare among Blacks, and among those of poor secioeconomic status. It thus follows that endometriosis is rare in Nigeria, where poverty is rampant and the population predominantly black. There is a marked regional difference in the incidence of endometriosis in Nigeria, however. Between September 1973 and February 1977, 28 cases of endometriosis (27 Blacks and 1 Caucasian) out of 1706 gynecological operations were observed at the Ahmadu Bello University Hospital in Zaria. A prevalence of 8.2% was noted, one of the highest reported among Negros. Average age was 45 years and average parity was 5. 18 were from the Hausa/Fulani tribe of the Savannah belt of Northern Nigeria. Majority were illiterate. Sites of the endometriotic lesions included the uterus (18 cases); ovary (7) fallopian tubes (2); and pouch of Douglas (1). Coexistence of adenomyosis, endometrial hyperplasia and granulosa cell tumors were also noted. These findings suggest that in certain areas, endometriosis is not rare in the Negro nor it it related to socioeconomic status.
[A Latin American overview of the programs of permanent control of fertility]
Sexual sterilization as a contraceptive method is very much used in the U.S., Europe, China, Russia, and India. It is, unfortunately, not included as such in the family planning programs of most Latin American countries, with the exception of Colombia, Guatemala, Cuba, the Dominican Republic, El Salvador, Nicaragua, and Ecuador. The example of these countries should be followed, were it only to diminish the growing number of illegally induced abortions. The greatest drawback to the use of sexual sterilization may very well be the attitude of most Latin American doctors: they have never been taught basic demography, whose implications they cannot comprehend; they have never been taught contraceptive methodology, and still attribute too much importance to reversible methods; and they are often not aware of the high risk which multiparity entails for mothers and children. The responsibility of medical schools is enormous. Another reason to explain the nonuse of sterilization as a contraceptive measure is the catholic church and the great power it exercises over governments, more than over the single individuals.
Unplanned and unwanted pregnancy constitutes a crisis situation, aggravated by various social aspects. Counseling in this situation is vital. Most abortion counseling occurs in abortion clinics, in family planning centers, and in individual doctors' offices. Personnel should be prepared to offer counseling wherever pregnancy testing is done. The abortion counselor should be prepared to mobilize the woman's coping skills and help her through the decision-making procedure, provide information on alternatives to abortion, provide technical information on the abortion procedure, and offer information and support throughout the process. The following groups of women will require special counseling procedures: 1) teenagers; 2) 2nd-trimester aborters; and 3) repeat aborters.
2 ways of administration of prostaglandins (PGF) were tested on a group of 100 patients seeking termination of pregnancy. Some patients were administered PGF 2 by alpha by endocervical injection, while some were administered it orally. The instillation technique gave remarkable results as it regarded the maturation of the cervix. There were a few unpredictable secondary effects, especially pain, but they were easily controlled with medication. (Summary in ENG)
The collaboration between the health authorities of the district of Kinkala, Rwanda, and the Association of traditional healers began in 1977. The Association of traditional healers, which includes 180 members, is in charge of cultivating those medicinal plants which are becoming rare, and to write a phytotherapy brochure naming all plants utilized in traditional practices, their origin, places of cultivation, and their use. Health authorities, on the other hand, have organized several health teams which regularly visit the 12 villages participating in the project, with the purpose to teach the population basic norms of health and hygiene.
[Why female sterilization in Latin America]
Data gathered all over Latin America, but especially in Chile, show that pregnancy and delivery before 20 and after 35 entail serious risks not only for the mother, but also for the child during its first year of life. The same data shows that at every age parity over 4 augments the risk of mortality for a new child. Such phenomenon is more serious in rural areas, where medical facilities are scarce, and in the lower socioeconomic classes of the urban population. It can be concluded that avoiding pregnancy before 20 and over 35, and avoiding multiparity would result in a decrease in infant and maternal mortality. Hormonal contraception and the IUD are not 100% effective and can have serious side effects, especially if one considers the fact that most women should rely on the pill or the IUD for about 25 years of their life, which no doctor would recommend. Female sterilization appears to be the best contraceptive method at least for those women who have reached their desired family size. Female sterilization is still illegal in most Latin American countries; this fact increments the use of illegal abortion as a contraceptive measure, with all its negative consequences.
[Permanent limitation of fertility in Bolivia and its effects on economic and social development]
Birth rate, fertility rate, and mortality rate, especially infant mortality, are very high in Bolivia. Internal migration is heavy, resulting in urbanization and related problems, such as unemployment, low educational level, cultural conflicts, displaced families, and criminality. Induced abortion, however illegal, is used as a contraceptive method. Fecundity is strongly influenced by education, place of residence, and by other social factors. In Bolivia there is no official organism to promote family planning or sex education; the government, and especially the church, have long ago adopted a strong pronatalist position. The church opposes any contraceptive procedure, and the status of Bolivian women is determined by old fashioned cultural and religious institutions. Fertility control is a problem which must be resolved at an individual level, since there are no organized family planning programs. However, there is no legal disposition against the sale of contraceptives, and they are available in a few pharmacies.
[Legal aspects of permanent control of fertility in Costa Rica]
The law in Costa Rica forbids induced abortion and sexual sterilization, unless advised by a doctor on therapeutic grounds. These legal limitations have created serious conflicts, some of which culminated in famous court cases. The deep rooted cultural habits and religious sentiments of the majority of the population will certainly not allow a change in attitudes in the next few years.
Ties between tubal sterilization, menstrual dysfunction examined.
The American Association of Gynecologic Laparoscopists conducted a debate on whether tubal sterilization is predisposed to menstrual dysfunction and to the increased need for future gynecologic surgery. In arguing that sterilization is not harmful it was pointed out that menstrual irregularities due to the disruption of uteroovarian blood supply may have occurred when unipolar electrocautery fulguration was used extensively, but it is not the case when using rings and clips. In addition, menstrual irregularities may be hidden by the use of oral contraceptives and recur when the pill is discontinued at the time of tubal sterilization. Also women with pelvic pathology that m ay later cause problems should have a hysterectomy not tubal occlusion. Arguments regarding sterilization as harmful include evidence suggesting that ovarian function impairment may be caused by tubal sterilization which in turn may cause menstrual dysfunction.
A literature review concerning the incidence of infection after an induced abortion is presented. Febrile morbidity is most frequent after abortions which are performed in the second trimester of pregnancy and after abortions which are performed in 2 stages, such as prostaglandin instillation. This rate is lowest among abortions perfomed by vacuum aspiration. The incidence of endometritis ranges from 1.9% after vacuum aspiration to 8.3% after 2-stage prostaglandin instillation. Other pelvic infections occur in .03%-3.5% of the cases, regardless of the procedure. The post-abortion incidence of sepsis ranges from .2%-1.9%, of urinary tract infections from .5%-4.2%, and of thrombophlebitis from .2%-1%. Genital infections after induced abortion may be due to cervical gonorrhea, incomplete evacuation of the uterus, or uteral perforation. Postoperative antibiotic prophylaxis can reduce the incidence of genital infections. Before the operation, local antibiotic suppositories are sometimes prescribed; cohabitation should not be resumed after the operation until after vaginal bleeding stops. Chronic adnexitis occurs in about 1.1-8% of abortion patients. Infections can cause closure of the Fallopian tubes or can affect the ovaries, causing sterility or infertility.
[Recent developments in fertility control]
New developments in contraceptive methods and fertility control for 1974 are enumerated. Combination preparations were tested which contained 30 mcg ethinyl estradiol instead of 50 mcg, to reduce the incidence of side effects. Low-dose and depot gestagen preparations are also being tested. Vaginal rings releasing progesterone work to inhibit ovulation or affect cervical secretions. Post-coital ethinyl estradiol or d-norgestrel administration is used as a contraceptive method. The Copper 7 IUD is preferred for nulliparae, while the Copper-T 200 is considered to be the best available IUD. IUDs which release progesterone or chloroquine are being tested. The Dalkon shield was removed from the market because of a higher incidence of infection. Plastic spermicidal film has not proven practicable as a contraceptive method. Better condom construction and better public promotion of condom use have been developed. Prostaglandins are not suited for menstrual regulation; use of the Karman catheter with pressure on the plunger instead of negative pressure has proven very successful. Abortion is best performed in the first trimester. Vacuum aspiration with preceding prostaglandin priming to prevent later cervical insufficiency is the preferred method. Female sterilization is best performed by laparoscopy with electrocoagulation. Clips and sterilization by hysteroscopy and chemical tubal occlusion are still in the experimental stages. During male sterilization, the proximal end is ligated and fastened under the fascia, while the other end is coagulated. This procedure guarantees reversibility in 75% of the cases. A 'male pill' and immunological contraceptive methods are also being tested.
A comparative study of the effect of the Progestasert TM and Gravigard IUDs on dysmenorrhoea.
A study was conducted at the Family Planning Centre of the Hospital Jose Joaquin Aguirre, Chile, involving 146 patients who had a Progestasert TM IUD inserted and 149 patients who had a Copper 7 IUD, Gravigard TM, inserted to determine the occurrence of dysmenorrhea. All patients completed questionnaires concerning habitual pelvic or genital pain prior to IUD insertion as well as at 1, 3, 6, and 12 months after insertion. Results indicated a reduction in menstrual cramps over 12 months of use. The Progestasert TM group showed a slightly higher reduction of menstrual cramps than Copper 7 users; however, the reductions are not significant. There were no significant differences between premenstrual and intermenstrual cramps. With the use of a questionnaire and the subjective condition of pain, it is difficult to ascertain whether the IUD produced any change in menstrual cramps or whether the reduction of pain originated in the patients; therefore, the technique of questioning the occurrence of pain may not be reliable enough.
Fertility in Women with Turner's syndrome: case report and review of literature.
Menstruation in women with Turner's syndrome can be spontaneous in 5% of women or can occur after estrogen therapy in types of hypergonadotrophic ovarian failure. Reports indicate that 56 pregnancies in 23 women occurred with 16 having 46,XX and/or 47,XXX cell lines. 27% of the women aborted and there were 4 stillbirths with 3 associated with congenital fetal malformation. 32% of the live births had physical or mental defects; 22% had abnormal karyotypes (3 with Down's syndrome and 5 with Turner's syndrome with a 45,X cell line). Premature ovarian aging may be the reason for the high frequency of abortions, stillbirths, and Down's syndrome. Because of the incidence of Down's syndrome among infants of women with Turner's syndrome, amniocentesis for fetal karyotyping is recommended.
Family planning programs must offer abortion services along with contraceptive services if the aim of these programs is to insure that all children both are wanted children. Although the ideal embodied in family planning is the prevention of unwanted births through contraception, it must be recognized that contraception, by itself, does not prevent all unwanted births. Contraceptive failures do occur. For example, women who use either the mini pill or the IUD experience a 2% failure rate. Unwanted pregnancies also arise when a client uses a method inappropriately. Women sometimes assume that oral contraceptives provide immediate protection and are unaware that protection is not assured until 2 weeks after the initiation of pill use. In addition, adolescents frequently fail to avail themselves of contraceptive services. Many adolescents believe that they cannot become pregnant, and others fear that their sexual activity will be discovered if they utilize available contraceptive services. Unwanted children, therefore, will continue to be born unless abortion services as well as contraceptive services are made available. The implementation of this dual approach would be an appropriate way to realize the goals embodied in the internation declaration of 1979 as the Year of the Child.
[Observations on abortion (letter)]
This letter investigates abortion not from a medical or therapeutic point of view, but from a psychological, religious and legal one. Abortion is many times requested not for ethical, economical or medical reasons, but to obey the rules imposed by a society that still ostracizes certain kinds of behavior. Sex education, adequate information and service on contraception, and a change in the social and economic status of women would solve many of the problems related to abortion.
The practice of traditional medicine in Africa.
Traditional medicine is a method of healing founded on its own concept of health and disease. Knowledge is passed on orally from father to son. Healing knowledge is jealously guarded in certain families. In Africa the popularity of traditional healers is attributed to the fact that they take full account of the socio-cultural background of the people. The components of traditional medicine include herbal medicine, therapeutic fasting and dieting, hydrotherapy, radiant healing therapy, venesection, surgery and bone-setting, spinal manipulation and massage, psychotherapy, therapeutic occultism, psychiatry and preventive medicine. In the African environment the therapeutic potential of traditional medicine is great and requires further indepth study to improve methods and training and to form a more effective organization within the ranks of traditional healers. In the physical medicine, vegetable, animal, and mineral substances may be used. In the metaphysical division of traditional medicine, prayers, invocations, or incantations are offered to some mysterious and powerful forces. The practioner usually excels in one or more practices to the exclusion of others. Herbal preparations should be studied with the idea of using them to replace more toxic, synthetic drugs. Some plants used by traditional healers are fennal, serpentine, cinchona, quinine, digitalis, and vinca rosea.
Abortion and the California Indian: myth and reality.
In 1979, a group based in Los Angeles, Indian Women United for Social Justice issued a declaration of prolife principles for all Indian women. Historically the California Indian has practiced abortion, infanticide, and contraception. If twins were born, especially of the opposite sex, one, usually the female, was killed. If a mother died in childbirth among the Maidu tribe it was buried with the body whether it was alive or dead. The Yurok encouraged abortion for premarital pregnancies, especially among the upper classes. The Yana tribe treated maturation as the most important and dangerous of life's traumas and separated the sexes as soon as maturation began. The Mojave Indians were different from their neighbors. They were more promiscuous and more warlike; they did not practice infanticide or abortion. California missionaries were strict and hated by most of their converts. Priests and administratiors could not tolerate the Indians' practice of abortion and flogged and punished women severely for miscarriages, adultery, and suspected abortion. Soldiers gave Indian women venereal disease and, because of their uniforms, were thought to be the same class as the clergymen.
The Wessex Abortion Studies; Interdistrict variation in provision of abortion services.
Analysis of reproductive patterns and abortion and abortion-related services in the health districts of Wessex showed considerable variation between districts in the provision of formal family-planning services. The patterns of fertility varied between districts and there was some relationship between family planning services and the rate for illegitimate and legitimate births and induced abortion. The region as a whole met the demand of 42% of its abortion patients within the National Health Service (N.H.S.). The considerable variations in the provision of services could be attributed to the attitudes of the women and of their general practitioners and consultants. Of Wessex women obtaining induced abortions privately at the British Pregnancy Advisory Service at Brighton, 85% said they would have been willng to have an N.H.S. operation locally if one had been offered. The differences in health services between districts are more likely to be explained by the attitudes of doctors to providing this service than by the wishes of women to use private medical treatment.
[Priming with intracervically administered prostaglandin alpha before abortion]
Prostaglandin F2 alpha (PGF2A) gel was used in 75 patients to prepare the cervix for induced abortion by vacuum aspiration. The intracervical application of the gel was administered 19 hours before the abortion operation. 5 minutes after administration, most patients experienced strong uteral contractions. Bleeding began 5 hours after the prostaglandin application; in 33 cases an incomplete abortion was observed. Nausea and vomiting were the most frequently observed side effects besides the pain of the uteral contractions. The gel was successful in every case. The extent of cervical dilation caused by prostaglandin gel could not be correlated to the age or parity of the patient or the length of pregnancy. Dosages between 2.5 and 3.0 mg of PGF2A gave the desired effect. Among 22 primigravidae, 13-24 years of age, an average of 2.7 mg PGF2A caused an average dilatation of Hegar 8.9. X-ray studies showed that the amniotic sac was completely enclosed by the gel 20 minutes after application. (Summary in ENG)
Despite the recent publicity given to studies pointing out the negative side effects associated with the use of oral contraceptives, the pill is still the most common form of contraceptive used in Great Britain and constitutes the form of contraception for many women. Some of the negative effects currently receiving wide publicity, no longer represent a serious threat for the pill user; many of these effects have been negated or ameliorated by modifying the composition of the pills. In combined pills the estrogen content has been reduced from 150ug to 20-35ug. In the 2 major studies linking oral contraceptives with the development of cardiovascular disease most of the women in the studied population had taken pills containing 50-100ug of estrogen. Given the wide choice of pills currently available, many of the negative effects, such as nausea and pain, cna be ameliorated by choosing a more appropriate oral contraceptive for the specific patient. Other side effects such as headaches and poor cycle control can be treated by regimen modification. Although there is a relationship between pill use and hypertension, pills containing levonorgestrel in combination with 30ug of ethinyloestradiol have only a slight effect on blood pressure. Lactation is not reduced for women who take progestogen only pills. Fertility is successfully restored in almost all women shortly after they stop using the pill. Drug interaction failures can be avoided in many cases by prescribing pills containing 50ug of estrogen for women taking other drugs. In order to obtain immediate effectiveness, the combined pill can be started on the 1st day of the period instead of waiting until the 5th day.
Abortion (Amendment) Bill. [Letter]
2 separate clauses of the British Abortion (Amendment) Bill are discussed. Clause 1 allows abortion up to 20 weeks where risk of life or serious injury to physical or mental health can be demonstrated. Clause 4 of the bill, according to the author, would result in increased difficulty for the women attempting to obtain an abortion. It requires signatures of 3 independent physicians before an abortion can be performed. Also, the amendment would prevent legal abortion by physicians in private practice, by charitable organizations, and the British Pregnancy Advisory Service. Currently The British Health Service lacks resources to meet the increased number of abortions it would be required to perform if the amendment is adopted. Consequently it is believed that the number of illegal abortions would increase in addition to the increased number of births of unwanted children.
Water intoxication after oxytocin-induced midtrimester abortion.
Water intoxication during or following oxytocin induced labor, albeit a rare event, can nevertheless cause potentially fatal complications or risk of neurological damage. Large doses of oxytocin plus large volumes of electrolyte-free solutions are the prime factors associated with water intoxication. Suggested treatment consists of hypertonic saline. Although circulatory overload and pulmonary oedema can occur from saline treatment it is believed that the risk of cerebral oedema is greater than risk from saline treatment. Prevention of water intoxication includes: 1) restriction of fluid intake; 2) monitoring of analgesia given; 3) interruption of continuous infusion; 4) fluid balance with control of serum electrolytes and osmolality; and 5) use of electrolyte-containing fluid as a vehicle for the oxytocin.
Vaginal prostaglandin E2 for interruption of pregnancy and management of intrauterine death.
This study assesses the efficacy, safety and acceptability of PGE2 (prostaglandin) vaginal suppositories for terminating pregnancies. The subjects were divided into 4 groups: 1) A (missed abortion, n=29); 2) B (termination of pregnancy, n=9); 3) C (molar pregnancy, n=3); and 4) D (late intrauterine death, n=12). 22 obstetricians (20 with no previous experience with PGE2) participated in this multicentre trial. 1 gm vaginal suppository containing 20 mg PGE2 was inserted into the posterior fornix of the 53 patients every 2-5 hours until the uterine contents were expelled. Satisfactory overall results were obtained in 52 women. Total cumulative expulsion rates were 40/53 (75%) after 12 hours, 51/53 (96%) after 24 hours, and 52/53 (98%) after 36 hours. Group B required a greater total dose of PGE2 and a longer 1st dose-expulsion interval than pregnancies complicated by fetal death (Groups A and D). Systemic absorption plays a role in the abortifacient efficacy of vaginally administered PGE2. This is why adequate myometrial stimulation has similar side effects as those seen during intravenous infusion of the compound. The severity and frequency of side effects experienced by the patients in this series can be reduced by means of premedication with a potent anti-emetic (haloperidol) and an anti-diarrheic (loperamide). (Summary in GER)
To measure physical sensations experienced by women undergoing saline abortion, 7 female patients were interviewed within 5-19 days after the abortion procedure with open-ended and fixed-choice questions which elicit recall of physical sensations. The group recalled a total of 105 distinct sensations, with each woman recalling a mean of 22 sensations. High incidence sensations according to the different phases of saline abortion (instillation, latency and labor; placental) were recalled by the women. Sensations recalled by at least 2/3 of the women interviewed were defined as likely sensations (Table 1). In describing their sensations, the women did not distinguish between the latency and labor phases, suggesting that distinction should not be considered when establishing an expectancy framework for the women. Also, the usual sequence of fetal passage first and then placental passage second did not occur predictably as described by the medical literature. These findings are applicable only to women in this series and those who have no concurrent medical problems or procedural complications. The findings about physical sensation can be utilized in preparing women to expect bodily sensations during saline abortion; nurses desiring to intervene can make use of these findings. The open-ended method of interviewing the small number of subjects in a predetermined way helped establish important information for nursing exploration and intervention.
1604 patients with laparoscopic sterilization were divided into 3 groups based on timing of sterilization relative to therapeutic abortion: 1) postabortion; 2) intermediate (sterilization performed 1-42 days after abortion); 3) interval group (sterilization performed 43 days after abortion). Patients were followed up from 7-21 days, 6 months and 12 months after the surgery. The 3 groups were compared as to immediate complications; early complications; patient characteristics and other relevant events (surgical time, surgical difficulties, procedure failures and pregnancy failures). Overall findings show that the 3 groups were generally comparable in their biologic characteristics. The postabortion group was gererally better educated than the other 2 groups, and there was a high incidence of previous induced abortions, with more than half of the subjects having at least 3 previous abortions. For both electrocoagulation cases and tubal ring cases, technical problems and major complications were minimal regardless of timing of therapeutic abortion. No serious complications were observed. It was concluded that combined therapeutic abortion-laparoscopic sterilization procedures do not increase risk of technical difficulties and complications.
Clinical uses of prostaglandins in human reproduction.
Prostaglandins have found clinical applications in: 1) termination of midtrimester pregnancy; 2) induction of labor; 3) menstrual regulation; and 4) control of postpartum hemorrhage. In abortion, prostaglandins (PGs) are used to bring about rapid dilatation of the cervix and diminished flow of the utero-placental blood. They are administered via intravenous, intra- and extra-amniotic, vaginal, and intramuscular routes, and are considered to be the most efficient and safest abortifacient known. Common side effects (nausea, diarrhea, phlebitis, fever, chills and rigors, hypotension, chest pains) can be controlled by simultaneous use of drugs such as Diazapan, Squil, Stemetil, Eskazil, and Lomotil. In cases of induction of labor (e.g., intrauterine fetal death or missed abortion), PGs have a success rate of 85-98%, with minor side effects. Although PGs are used to regulate menstruation, accompanying side effects make their use for this purpose almost unacceptable. In addition, their role in controlling postpartum hemorrhage has been found to be insignificant. A clinical trial of 341 healthy pregnant women who had abortion using PGs is briefly described.
Regulating abortion services. [Letter]
It is ironic that the informed-consent provisions regarding abortion of the Akron legislation indirectly require doctors to lie to their patients regarding the risks involved in abortion. Also, the idea that a description of the fetus is not relevant to a woman's decision to abort is to deny the possible existence of a second human being. If the existence of a second being is established, then describing fetal characteristics should not prejudice a woman's decision to continue the pregnancy, nor should it produce guilt feelings over the decision to abort the pregnancy. If however, description of fetal characteristics questions the presence of a second being, then this information is important to the woman's decision. Describing the fetus as fetal tissue or products of conception and conveying an image of a blood clot or placental fragment is an understatement. As women do not take lightly the decision to abort their pregnancies, they have the right to be informed of what is being removed before they make the decision. Ethical considerations are involved in the abortion issue, and women contemplating abortion should not be deprived of the description of the fetus, whether or not she requests it, if they are to give truly informed consent.
Lactational amenorrhoea, prolactin and contraception. [Editorial]
Data from developing countries show that lactational amenorrhea, nature's own contraceptive but which Western societies regard as unreliable because ovulation often occurs before menstruation returns, can have a profound effect on fertility. Among certain African tribes, breastfeeding practices result in birth intervals ranging from 35.4 months-23 months, depending on food supplementation practices. Traditional patterns of frequent suckling without food supplementation are essential in maintaining the contraceptive effect of prolonged lactation. Suckling stimulates prolactin release from the anterior pituitary, and basal prolactin levels have been related to both frequency of suckling episodes and duration of lactational amenorrhea. It is not known however, whether prolactin acts directly on the hypothalamus, on the ovary, or both. It can be hypothesized that suckling induces raised prolactin levels which inhibit the normal positive feedback effect of estrogen on the hypothalmus; this results in decreased LHRH (luteinizing-hormone-releasing hormone) and loss of LH pulsatile secretion from the pituitary, thereby suppressing ovulation. Further research should be done on the relationship between suckling frequency and prolactin levels and the events which control ovulation; such research may lead to the development of a new, effective and safe method of contraception.
Professional and public opinion on abortion law proposals.
Subsequent to the 1977 New Zealand Contraception, Sterilization and Abortion Bill, 4 amendents relating to authorization of abortion requests were proposed. Consequently, in an effort to determine public and medical professionals' opinions about the amendments, 4 surveys were undertaken. Results showed that approximately two-thirds of doctors approved of legal abortion upon agreement of 2 doctors and when the Director-General of Health performed his usual regulatory role. A majority of doctors in a 2nd survey indicated that the question of abortion should be a matter between the woman and her physician in the 1st 3 months of pregnancy. When nurses were questioned, results showed a clear majority supporting the amendment allowing the woman and 2 financially independent doctors to decide. However, when 1000 randomly selected individuals were questioned, approximately two-thirds favored a more liberal amendment allowing the woman and her physician to determine whether an abortion should be performed.
Collection and analysis of data on rural women's time use.
A UNESCO-sponsored Project for Equal Access of Women and Girls to Education was designed to run from 1965-75 in Upper Volta and promote educational opportunities for females, allowing them to provide increased contributions to the nation's social and economic development. The project began with a collection of information to assess obstacles preventing the access of girls and women to education. Initial pilot projects sought to lighten women's work loads through the introduction of technology. The time-use data showed that, in the 1st 14 hours of the day, women performed 64% of the food production/distribution/supply tasks, 23% of the crafts and other professions, 97% of household tasks, and 23% of community obligations. The women's work made up 56% of all work performed in that period. Female workloads after this 14-hour period of observation were expected to rise since the evening meal was not included in the data collection time period. Women with co-wives had reduced workloads. Age did not affect women's time use; females began to put in longer work days than males at the age of 7. The availability of technology, e.g., food preparation machines, did not lighten the load. The data collected indicate that women's work loads must be lightened before they can benefit from increased educational opportunities.
New abortion legislation: a comparison with professional policy.
The Contraception, Sterilisation and Abortion Act 1977 and the Crimes Amendment Act 1977 recently enacted by the New Zealand Parliament are compared with policies regarding induced abortion which have been adopted by national health professional organizations. The spirit of the Act and most of the detailed provisions concerning abortion are restrictive and inconsistent with the policies of most professional organizations in the field. The Act prescribes a supervisory committee to oversee abortion decision-making, whereas most of the professional organizations favor the decision being an individual one by the woman or a joint woman-doctor decision. Committees are feared by health professionals for the delay they cause. Restriction of the grounds for granting abortions goes against the stated policy of all the health professional organizations. Most of the organizations favor licensing of places which perform abortions, but the licensing requirements of the new Act are felt to be too restrictive. Most professional organizations favor the Act's protection for health professionals who do not wish to perform or assist with abortions on the grounds of conscience.
[Abortion and the use of anesthesia: observations after two years' experience (author's transl)]
The authors report on their experience with anesthesia in 380 cases of induced abortion. Paracervical block was used in 39 cases, (10.2%), with no complications. General anesthesia was used in 3 different ways: 1) narcoanalgesia combined with propanidid and dextromoramide, used on 103 women (21.1% of cases), resulted in a large number of cases of vomiting; 2) narcoleptoanalgesia with propanidid, dextromoramide and droperidol, used on 143 patients, (37.6%), resulted in fewer cases of vomiting; and, 3) narcoanalgesia with CT 1341 and dextromoramide, used on 79 patients, (20.7%), resulted in an even smaller number of cases of vomiting. (Summary in ENG)
Termination of pregnancy in Gisborne.
The 182 abortion cases referred to the Cook Hospital in Gisborne, New Zealand from November 1973 to December 1975 were analyzed in regard to referral patterns, operative methods, pregnancy duration prior to abortion, complication rates, and patient characteristics, including their contraceptive practices before and after abortion. The results of the analysis were compared to data on a series of New Zealand women who obtained abortions in Melbourne, and to abortion data obtained from the Auckland Medical Aid Center. The abortion rate among Gisborne residents increased markedly from 0.37/100 live births in 1969-1973 to 17.9/100 live births in 1976. The 182 patients were referred to the hospital by 16 of the 19 doctors practicing in the areas, and in general, the % of patients referred by each doctor for termination was proportional to the % of patients delivered by that doctor at the hospital. Of the 182 patients referred, 170 were subsequently aborted. Most of these women were aborted by vacuum aspiration. 12% of the abortion patients were less than 21 years of age and 25% were over 30 years of age. 4.4% of the patients were nulliparous and 15.6% had 5 or more children. 46.8% were single. Over 50% of patients used no contraception during the conception month. Following the abortion, most patients practiced contraception. 20% were sterilized, 40% took oral contraceptives, and 13% used injectables. 75% of the patients who still live in the area continue to attend the hospital's family planning clinic. Tables provide: 1) abortion rates for Gisborne residents, and 2) distribution of abortion cases by operative method, gestation duration, complications, parity, marital status, age, and contraceptive practice before and after conception.
Termination of pregnancy complicated by anencephaly with intra-amniotic prostaglandin F2-alpha.
Present methods of terminating anencephalic pregnancies over 20 weeks gestation before term are unsatisfactory. Using PGF2-alpha (prostaglandin F2-alpha) doses for 2nd trimester abortions result in hyperstimulation and complications when administered intra-amniotically during the 3rd trimester due to myometrial sensitivity to prostaglandin. However, while monitoring intrauterine pressure, PGF2-alpha can be administered incrementally with an initial dose of 5 mg and a doubled dose/hour afterward until a contraction pattern is established and successfully terminate an anencephalic pregnancy. Less satisfactory methods include: 1) awaiting spontaneous labor; 2) inducing labor with amniotomy and oxytoxics which are often long or fail due to myometrium insensitivity to oxytocin and ergot derivatives; and 3) performing a hysterotomy which accompanies high morbidity and mortality rates.
This brief historical survey documenting the use of ergot alkaloids throughout Ancient times for obstetrical purposes (labor induction and control of uterine hemmorrhage) takes its data from works of Theophrastus (who wrote Enquiry into Plants around 300 B.C.), Pliny, Dioscorides, and others. What this history documents is another source for the ergot besides the fungus Clavicips purpurea; notations from Greek, Mexican, and English catalogers show that the family Convolvulaceae is a constant source of ergot alkaloids; this family is the home of Rivea corymbosa, the morning glory seed used by Mexican Indians for both medicinal and religious purposes. In addition, an argument made from salient quotations from historical texts indicates that Scammony may also contain ergot alkaloids, although such compounds have yet to be chemically isolated. Only 1 extant study intimates the possible existence of ergot-like activity in Scammony, a study which showed that small doses of an ether extract of Scammony resin stimulated an isolated guinea pig uterus. If Scammony does contain ergot alkaloids, it is suggested that it will be an excellent source for this material, since the plants cultivation is inexpensive and easy.
The probability of side effects with Ovral, Norinyl 1/50 and Norlestrin 1.
Prevalence rates of various side effects were studied comparatively among 3 oral contraceptive preparations containing 50 mcg of the estrogen component. Norinyl 1/50, Ovral, and Norlestrin 1 were each randomly assigned to groups of 160 healthy women who had consented to participate in the study designed to quantitate probabilities of experiencing specific side effects and of their continuing into the subsequent cycles. Acne, breast discomfort, nausea, abdominal bloating, headache, fatigue, depression, irritability, vaginal discharge, and breakthrough bleeding were the specific side effects studied; only breakthrough bleedings showed a statistical difference in prevalence. The rate of breakthrough bleeding associated with Ovral use in the 1st 3 cycles (16.6%) was significantly (P < .05) lower than that associated with using either Norinyl or Norlestrin (46% and 51.7%, respectively). Norelestrin, aside from breakthrough bleeding, was reported as generally freer of side effects than the other 2 preparations. The probabilities of side effects being experienced in the 2nd or 3rd cycle after the effect(s) was experienced in the 1st cycle showed that overall, for all 3 combination pills, the probabilities significantly decreased from the 2nd to the 3rd cycle (P < .05). Also examined was the probability that a side effect would occur in the 2nd or 3rd cycle if the user had not experienced such an effect in the 1st cycle. In each instance, the probabilities are significantly lower (P < .05) than the corresponding probabilities where the symptom had been experienced in a previous cycle. These data support the contention that side effects experienced on inititation of oral contraceptives should not prohibit its continuation because the majority of symptoms will disappear as the patient becomes accustomed to the hormonal preparation.
Intravaginal contraception with the synthetic progestin, R2010.
The clinical performance as well as effects on gonadal and pituitary functions were analyzed during use of a contraceptive vaginal ring (CVR) impregnated with R2010, a synthetic progestin. 4 regularly menstruating women aged 25-29 years, who were parous and married, volunteered, and treatment was given in 3-week periods, leaving 1 treatment-free week. The CVR was a polysiloxane ring of core design and contain 50 mg of norgestrienone. Bleeding patterns were registered along with plasma R2010, progesterone, estradiol, and gonadotropins (luteinizing and follicle stimulating hormones). A total of 12 cycles were studied for this investigation. Bleeding patterns were unsatisfactory. Only 1 of 4 subjects had regular, simulated menstrual bleedings; 2 of these bleedings were preceded by a luteal phase (according to hormone assays). Mean plasma concentration of the progestin produced by the rings was .9 ng/ml. In 25% of the cycles ovulation was observed; in addition, some follicular activity was present in all 4 subjects, based on measurement of estradiol peaks. Mild pituitary suppression was achieved in the 3 subjects who did not ovulate. An acne flare-up constituted the only reported side effect.
In conjunction with a multicentered multinational study of the efficacy of a single suppository of 3 mg of 15-methyl-prostaglandin F2 alpha methyl ester (PGF) for abortion of 1st and 2nd trimester pregnancies, this study of the drug's vaginal absorption, plasma absorption, and plasma half-life was undertaken. 25 healthy women, 10-12 weeks pregnant, were studied; they were arbitrarily divided into 6 groups, and each participant received a single vaginal suppository of the PGF. Plasma levels of the drug (both the methyl ester and free acid forms) were measured at differnt time intervals following suppository insertion by using deuterated carriers and bas chromatography-mass spectrophotometry. PGF (sum of methyl and acid forms) had a mean value of 1166 pg/ml of plasma 3 hours after treatment. Mean levels were maintained in the range of 1000 pg/ml in subsequent measurements (in 3-hour intervals up to 30 hours). Preliminary studies showed that, unlike women who successfully aborted, those who failed to abort within 30 hours with this vaginal suppository were unable to maintain these high plasma levels for a sufficient period of time. Within this study are reports of side effects attributable to PGR (diarrhea and vomiting), body surface areas, and induction-abortion interval in relation to the plasma levels. Out of the 25 patients, 5 failed to abort within the 30-hour criterion set for the study, giving a success rate of 80%. Mean episodes of diarrhea and vomiting were 1.88 and 2.2, respectively. No correlation was observed between the plasma levels of drug at different time intervals and the episodes of side effects. Similarly, no correlation was found between the body surface area and induction-abortion interval with the plasma levels of drug.
Role of the media in the introduction of technology.
Any media campaign designed to introduce MR (Menstrual Regulation) should be preceded by good, consistent studies, dissociated from feminist activities, possibly a new name, and a definition of who should get it, when, where, by whom, and at what cost. MR started off on the wrong foot when it was introduced to the media by radical feminists who recommended it for shortening the menstrual period. Studies should be conducted in Planned Parenthood clinics to show that MR offers real advantages to women faced with a potential unwanted pregnancy. The premature introduction of an ill-defined procedure can lead to a disaster similar to what happened with the IUD in some countries. One or two bad complications could give all abortions a bad name. "Miniabortion" might be a more acceptable name than the euphemism, Menstrual Regulation. When pregnancy is detectable within the first few days of gestation, MR will be a laughable name. A major New York City clinic provides MR only for women with negative pregnancy tests on the day of the procedure. If your pregnancy test is positive you have to get the expensive first-trimester abortion instead of the less expensive MR. It is recommended that the abortion fee be downscaled to one fee for both operations, rather than raising the MR fee to that of abortion.
State attempts to stem decline: Hungary.
The population policy in Hungary includes a system of benefits that provides support for women in pregnancy, confinement and during the post-delivery period; and increased maternity benefits, family allowances and State support for the care of children. Every Hungarian woman employee is eligible to receive full wages during the first 5 months after delivery and to child-care allowances up to the 3rd birthday of the child. The development of improved housing is considered an important part of population policy. Over 2/3 of the women in the fertile age range 15-44 in Hungary are full-time workers and efforts are being made to eliminate much of the conflict between a woman's dual role as mother and worker. The most important aspect of Hungary's population policy is the revision of the regulations controlling induced abortion, which took effect in January 1974. For 18 years before that induced abortion was legal provided it was carried out in a recognized institution with formal permission from an abortion committee. The change in the law resulted in an abrupt drop of about 40% in the incidence of abortions -- from 1024 abortions/1000 live births in 1973 to 514/1000 in 1974. The number of abortions on medical grounds increased from 4000 to 12,000. A 1977 Hungarian fertility, family planning and birth control study revealed no substantial change in the number of women using contraception, or in desired family size, between 1974 and 1977. Contraceptives are available for anyone wanting them. The 1977 survey makes the point that the sharp fertility increase following these pro-natalist measures may well have been a temporary phenomenon.
Anovulation after pregnancy termination: ovarian versus hypothalamic-pituitary factors.
28 female rhesus monkeys were studied after induced abortion or after spontaneous delivery at term to differentiate ovarian from hypothalamic-pituitary factors responsible for suppression of ovulation. Human menopausal gonadotropin (HMG) was administered to stimulate follicular maturation, and estradiol benzoate was injected to test induction of gonadotropin surge. Spontaneous ovulation was delayed until about 39 days after abortion. The presence of multiple preovulatory follicles on both ovaries confirmed that folliculogenesis had been stimulated by HMG, which also caused the maturation and rupture of these follicles. These findings show that pregnancy does not hinder gonadotropin stimulation on the ovaries, but that it suppresses hypothalamic-pituitary responsivity to the positive feedback action of estrogen on FSH and on LH surges. It is possible that tonic gonadotropin secretion is inadequate to initiate follicular maturation until late in the puerperium.
A study of repeaters of abortions.
Since the inception of legalized abortions in New York City in July 1970, there has occurred a definite increase in the number and percentage of New York residents who have had repeat abortions. Abortions increased from 69,711 to 85,590 from 1972 and 1974. The number of women having repeat abortions for this same period increased from 13.6% to 21.5%. The increase in the number of "repeaters" exceeded the increase in the number of women undergoing a 1st abortion. In order to further assess this trend, certificates were reviewed for the period 1972 to 1974 and information collected on the characteristics of women having repeat abortions as well as those having 1st abortions. All ages and ethnic groups were involved in the increases for "repeaters." The nonwhite group accounted for over 1/2 the increase. The rate of increase in the number of abortions was highest for the Puerto Rican women, followed by the nonwhite women, and lowest for the white women. 21% of th "repeaters" were "multiple repeaters." "Repeaters" were more likely to be somewhat older and to have had a previous birth or births compared to those having a 1st abortion. "Repeaters" also tended to have earlier terminations and this remained true for each age and ethnic group. 50% of the "repeaters" used the free standing clinics and 25% used municipal facilities. Over 60% of those having a 1st abortion used these same facilities. All facilities must accept responsibility for providing family planning counseling services to all women seeking abortions and particularly to "repeaters."
Abortion complications associated with methods of payment.
Medical, demographic, and social economic data were gathered on women who had induced abortions in hospitals where abortions were performed in the state of Hawaii from March 11, 1970 through December 31, 1973 in order to identify which categories of women experience higher rates of complication and the reasons for these higher rates. The method of payment is used as the basis for identification, for generally this is an indicator of both the social status of the woman and the medical care options open to her. Complications were recorded by the attending physician prior to discharge or when a woman was rehospitalized for treatment of abortion related complications. Minor complications occurring after discharge are excluded. There were 16,523 consecutive induced abortions performed during this period with an overall complication rate of 72/1,000 abortions. The overall complication rate differed markedly by method payment, varying from 57/1,000 to 110/1,000 abortions. Women whose abortions were paid for by welfare, military or parents had approximately twice the complication rate of those whose abortion were paid for privately or by health insurance. It was demonstrated that the reasons for these high complication rates in certain method of payment categories is due primarily to the characteristics of the services and not the women. Since a woman's status is the major determining factor concerning the type of medical services available, many women obtaining abortions are not in a position to receive optimal medical care. Social work intervention on several different levels is recommended as a possible means to equalizing the system.
Lactation and amenorrhea life tables from the 1974 National Acceptor Survey.
In developing countries, breastfeeding is common and is often prolonged due to the belief that it is effective in postponing the next conception; it is, therefore, an important determinant of the proportion of Filipino women protected from pregnancy. Also, breastfeeding is an important variable for nutrition and demographic surveys. Life table analysis of breastfeeding shows that lactation extends the period of postpartum amenorrhea from 3.4 months to 5.8 additional months. Promotion of breastfeeding should be an important component fo family planning.
Morbidity and mortality from second trimester abortion: a decade's perspective.
This is a review of the data on morbidity and mortality resulting from 2nd-trimester abortion methods used over the past decade. Methodological considerations involved in evaluating the safety of various abortion methods are mentioned. Descriptive, analytic, and experimental approaches are possible. The authors feel that observational studies, repeated in different places and analyzed with proper statistical techniques, are the most useful approach. The largest comparative studies involving 2nd-trimester methods are cited. All 6 comparative studies carried out in the U.S. which have compared dilatation and evacuation ( D & E) with intraamniotic abortifacients have found the D & E procedures to have lower complication rates. Generally, prostaglandins are found to be faster than saline; prostaglandins, however, cause more minor complications and they can result in a live-born fetus. Combinations of abortifacient agents are now in use. The incidence of abortion-related deaths is decreasing, probably due to the increased availability of legal abortion. This decline is attributed to the trend to earlier abortions, to increasing experience among physicians, and to increasing use of the safer techniques, e.g., curettage. Mortality rates connected with D & E and saline procedures have decreased constantly. Both of these methods and prostaglandins have lower mortality risks than hysterotomy and hysterectomy.
Leprosy and female genital organs: a preliminary report.
A study was conducted using 14 female leprosy patients attending the Leprosy Clinic at Nehru Hospital in Chandigarh, India, to determine the effect of the disease on the female reproductive organs and lifetime menstrual cycle. Leprosy was found not to have a direct effect on menstruation or fertility. 1/2 of the patients had no correlation between the disease and any obstetrical or gynecological event. The other 1/2 experienced either the onset of the disease or worsening of the symptoms at menarche, pregnancy, or menopause. This occurrence may be explained by the lowered body resistance during these obstetric or gynecologic events. None of the endometrial biopsies showed leprous granulomas or tubercule bacilli. Smears from menstrual blood revealed no lepra bacilli. This constitutes indirect evidence that there is no direct involvement of female genital organs in leprosy.
Intra-amniotic prostaglandin F2alpha and urea for midtrimester abortion.
A study involving 115 women was conducted to determine the effectiveness of doses of PGR2alpha (prostaglandin F2alpha) and urea for 2nd trimester abortions. 2.5-20 mg of PGF2alpha was combined with 80 gm of urea to induced abortion, with 10 mg being the optimal dose. Only 2 patients had not aborted after 36 hours and only 6 patients required a 2nd injection at 24 hours; laminaria tents did not shorten abortal times. For 33 multiparous patients the mean abortal time was 14.3 hours and for 82 nulliparous women, the mean abortal time was 16.4 hours. 30% of the women had the placenta removed operatively using intravenous sedation. Vomiting occurred in 19 women, nausea in 4 women, 8 became febrile, 2 received blood transfusions for hemorrhage, and 2 had a 4-cm cervical laceration
The augmentary effect of intramuscular prostaglandins on ethacridine lactate.
50 women between 15 and 35 years old, who were 13-20 weeks of gestation, were administered 100 ml or 0.1% ethacridine lactate and at 3-hour intervals were given 2 intramuscular injectins of 15-methyl-PGF2-alpha (300 ugm each) for termination of pregnancy. The success rate was 88% with a shortened average abortion time of 21.26 hours; the incidence of incomplete abortion was 8%. Gastrointestinal disturbances were not reduced appreciably despite the limited prostaglandin injections. Using ethacridine lactate combined with prostaglandin was more successful than ethacridine lactate alone but inferior to prostaglandin use alone.
Studies in the involvement of prostaglandins in uterine symptomatology and pathology.
A clinical study was conducted to determine the levels of prostaglandin present in endometrial tissue during various phases of the menstrual cycle. Endometrial tissue was taken from 155 women who had a curettage or hysterectomy. The samples were divided into 2 groups: 1) those women with regular and normal menstrual cycles; and 2) those women with uterine symptomatology or pathology. Within these groups, the tissue samples were divided into groups according to menstrual phase--proliferative, early secretory, late secretory, or menstrual. Concentrations of prostaglandins E2 and F2a in the endometrial tissue of women with normal uterine function at the 4 defined periods are tabulated. So are the prostaglandin data from the women with uterine symptomatology or pathology at 2 phases of the cycle. The study results show that both these prostaglandins appear to be involved in uterine physiology. Particularly elevated levels are associated with dysfunctional uterine hemorrhage in some patients and dysmenorrhea in others. The concentrations of both these prostaglandins in endometrial tissue from healthy women were higher in the late secretory and menstrual phases. In the proliferative and early secretory phases, prostagladin E2 was present at higher levels. It is suggested that the increase in concentrations of prostaglandins is possibly associated with the secretion of estradiol.
Results of a continuing study on dysmenorrhea are reported. 10 subjects were monitored for this study. 2 were normal nondysmenorrheic women, 6 were dysmenorrheic and participated in an Ibuprofen trial, and the remaining 2 were mildly dysmenorrheic-severely dysmenorrheic whose symptoms had abated on oral contraceptive therapy. Menstrual fluid volume and prostaglandin (PG) production were measured in the 3 groups; in the dysmenorrheic women (n=6) who were not treated with oral contraceptives, significantly higher menstrual fluid volume and menstrual PG release were measured compared with controls and oral contraceptive-treated women. The 6 dysmenorrheic women previously untreated were then enrolled in a standard double-blind cross-over study using Ibuprofen and placebo. 28 cycles were monitored. Ibuprofen, administrated prophylactically, 400 mg 4 times/day, considerably reduced the PG release in menstrual fluid but not the volume of menstrual fluid. Hence, it is concluded that primary dysmenorrheic symptoms are caused by high PG levels in menstrual fluid, not by fluid volume.
Menstruation induction, preabortion cervical priming, and midtrimester abortion are described, as achieved by using vaginal suppositories of 15-methyl-prostaglandin F2 alpha (15-ME-PGF2A). Studies of volunteers amenorrheic for no more than 49 days constituted the menstruation induction experiments. Initially 3-mg suppositories were inserted, the patient was watched in the hospital for 10 hours, and then she was discharged. 2 weeks later at followup, all patients had experienced vaginal bleeding, and 1 abortion was reported. At followup, 15 of 20 (75%) had negative pregnancy tests. The success rate was upped to 100% when the dosage schedule was altered to administration of a 1-mg suppository followed 3 hours later by the 3-mg suppository. Vaginal suppositories of 15-ME-PGF2A in 1-mg amounts were also used for cervical priming in 13 first trimester abortion candidates. 3 of 13 aborted before surgical evacuation. In the remaining patients dilatation of the cervix to 8.2 + or -3.9 mm was achieved. 5 patients required no mechanical dilatation at surgery. Treatment commenced 12 hours before pregnancy interruption. The abortifacient effectiveness of a 3-mg dose of this analog in a vaginal suppository followed in 24 hours by intramuscular injections of 250 mcg every 2 hours was evaluated in 40 volunteers in midtrimester of pregnancy. The suppository alone induced successful abortion in 22, with a mean abortion time of 14 + or -3.8 hours. 17 patients received an average of 3.5 subsequent intramuscular analog doses, and the success rate of 97.5% reflects only 1 failure. Side effects included vomiting and diarrhea, but none were serious.
A maternal death associated with prostaglandin E2.
A case of maternal death associated with late abortion by prostaglandin E2 (PGE2) for in utero fetal death is reported. The woman was a 30-year-old gravida 2, para 1, admitted with intrauterine fetal death. Her family history of cardiovascular disease, especially myocardial infarction, is emphasized. 2 20-mg vaginal suppositories were inserted at different times to dilate the cervix, and placenta was evacuated by vacuttage. She was realeased the next day. 9 days later the patient was readmitted to the hospital with chest pains, and a lung scan was positive for pulmonary embolism, but a cardiac scan was negative for myocardial infarction. Her lipid profile was type IV. Cardiac arrest occurred, and she died 12 hours later despite attempts at resuscitation. Autopsy revealed a large transmural anterior myocardial infarction associated with an extensive fibrinous pericarditis obliterating the pericardial sac. There was severe generalized cornonary arteriosclerosis, with 95% occlusion of the left main coronary artery. This is the 1st reported fatality associated with PGE2 vaginal suppositories.
Prostaglandins and prostaglandin antagonists in female reproduction: an overview.
This monograph chapter reviews the role of endogenous prostaglandins (PGs) and PG antagonists in female reproduction. In laboratory rodents, PG or metabolites of arachidonic acid are essential for follicular rupture and release of fertilizable oocytes, for cycle regression of the corpus luteum, and for delivery of normal, live offspring. In humans, PGs seem to modulate ovum transport, help initiate decidual reaction, help adapt uterine blood flow, and have a part in regulating the partition of the fetal cardiac output between the pulmonary, systemic, and placental vascular beds. PGs arise throughout the female reproductive tract, apparently in response to gonadotropins and steroid hormones. Inhibitors of PGs have been successfully used to control dysmenorrheic symptoms, menorrhagia, preterm labor, and ovarian hyperstimulation syndrome in humans. PGs are useful as an aid to uterine evacuation in humans, and have the ability to synchronize estrous in farm animals. PGs have been implicated in the following physiological and pathological processes: 1) smooth muscle contractility; 2) modulation of adrenergic transmission; 3) regulation of vascular tone and blood pressure; 4) platelet aggregation; 5) female reproduction, including ovulation, ovum transport, implantation, luteolysis, menstruation, labor, and abortion; 6) hormone production and modulation of hormone action; 7) gastric acid secretion and intestinal motility; 8) inflammation and pain reactions; 9) pyrexia; 10) modulation of immune response; 11) regulation of cell growth; 12) calcium ion absorption from the bone; 13) renal function; and 14) intermediary metabolism.
Uterine rupture with the use of vaginal prostaglandin E2 suppositories.
A case of spontaneous rupture of the uterus following induction of labor for mid-trimester abortion by intravaginal prostaglandin E2 (PGE2) suppositories is reported. Recent approval of this drug by the Food and Drug Administration for the abortion of mid-trimester pregnancies and induction of labor in association with death in utero and benign molar disease increases the actuality of the present case study report. Prostaglandins increased intrauterine pressure to levels beyond that of normal labor. This case raises questions about the currently unlimited use of vaginal PGE2 suppositories with previously scarred uteri. In retrospect it needs to be assumed that uterine rupture in this case occurred within the first 12 hours of labor, prior to oxytocin stimulation. A decrease in uterine size and cessation of labor represent fairly typical signs of uterine rupture. Other classical signs, such as vaginal bleeding and peritoneal irritation as a consequence of intraperitoneal hemorrhage, severe pain, and unstable vital signs were lacking and resulted in a delay of diagnosis. If PGE2 suppositories are to be used in previously scarred uteri, caution needs to be taken in order to recognize early signs of uterine rupture. The vaginal route of prostaglandin administration may carry the same risk for uterine rupture as reported for the intra-amniotic installation.
Reply to Dr. Grimes and associates. [Letter]
Dr. Grimes and colleagues focused on the advantage of midtrimester abortion performed by dilatation and evacuation rather than by the pharmacologic methods more commonly used at this time. It needs to be pointed out that there has not yet been conducted a randomized study systematically comparing surgical evacuation with other methods in 2nd trimester pregnancy. When such studies are performed, it will be necessary to evaluate early risks and complications and the late sequelae as they affect the woman's long range productive potential. Grimes et al. reported in previous findings that in weeks 13-20 of gestation cervical injury was twice as frequent and uterine performation more than 6 times as frequent with dilatation and evacuation as compared with the saline-infusion technique. Dr. Grimes is correct that a high incidence of incomplete abortion is not inevitable if surgical management alone is used. Also, a well-managed saline- or prostaglandin-induced abortion ends in "complete" abortion. The fact that as many as 1/2 of such abortions are associated with temporary placental retention after passage of the fetus does not imply a pathological state per se; surgical completion of these cases is conducted easily in almost all by simple placental removal through a well-prepared and already dilated cervix. New information continues to become available concerning the dangers of late sequelae of 2nd trimester abortion. The safety of rapid forceful dilatation of the cervix in advanced pregnancy remains to be proved.
Widening women's choice: Austria.
There is no explicit government policy on population in Austria, but in response to the dramatic post World War 2 decline in the birthrate, measures have been taken to encourage mothers to stay at home with their children. A woman is entitled to eight weeks' leave on full pay before and after her child's birth, and she can apply to have at least 1 year away from work after the birth on 1/2 pay. Another result of the low birthrate is that it is very difficult to obtain any further funds for improvement in the family planning and abortions services -- much needed improvements. The abortion law is also restricted in practice. Austria is a predominantly Catholic country, and the medical profession is very conservative. Many physicians conscientiously object to performing abortions in hospitals. Privately, physicians charge high prices so that it is less expensive for many women to go to London or Holland to have an abortion. Although it is comparatively easy to get an abortion in Vienna, in some areas it is extremely difficult. Although a few women's groups are pressing for change in both family planning and abortion services, on the whole the issue is dead. Elisabeth Jandl-Jager, a psychotherapist involved with the Austrian Family Planning Association, maintains that 1 of the foremost roles for the Association is to dispel the misconception that the provision of family planning and abortion services in itself decreases the birthrate.
The relative value of two concentrations of hypertonic saline for midtrimester abortion.
359 17-20 weeks-of-gestation pregnancies were terminated by intraamniotic hypertonic saline at 2 strengths to determine and compare the safety and efficacy of this technique at each dosage level. 150 women received 5% saline and 209 received 20% saline; the 2 doses randomly assigned. Data were collected for the India Fertility Research Program. Incidence of method failure in the 5% group was 9.4%; the 20% group, 7.2%. Incidence of incomplete abortion was not significantly different between the 2 groups. Abortion rates were significantly higher at 24 hours for the 20% group (P<.05), but the difference was no longer significant after 36 hours. Mean induction-to-abortion interval was greater in the 5% group (30.1 hours) than for the 20% group (28.8 hours). Excess blood loss and fever occurred significantly more frequently in the 5% vs. the 20% group (P<.05). A total of 6 deaths occurred; 5 were in the 20% saline group (2.4%), and 1 was in the 5% saline group (.7%).
Minimal risk of Rh sensitization in induced abortions.
Evidence from almost 700 consecutive first trimester abortions and 59 random second trimester abortions leads the author to question the need for administering full doses of anti-D globulin to legal abortion patients of Rho-negative blood type routinely. Of 699 first trimester cases, only 17 tested positive for fetal cells. All 17 had less than 2 ml of bleeding, and the remaining cases had no transplacental bleeding; these cases were aborted by curettage. A higher percentage (10%) aborted by saline tested positive, but as in the vacuum curettage group, all bled less than 2 ml. A 20-unit dose, vs. the standard 300-unit dose, is recommended.
275 married women who were admitted to the Institute of Gynecology and Obstetrics in Poznan for abortion, were interviewed and given questionnaires. Despite the fact that all stated that abortion is a last resort and not really another means of birth control, answers reflected a dubious familiarity with various contraceptives. Only 12.2% felt that contraceptives were satisfactory, 44% described them as being ineffective, 20.9% as harmful and 5.4% as inconvenient. Women over 30 did not complain that contraceptives stifle sexual satisfaction, and those over 39 did not speak of inconvenience. All said that abortion may be harmful to physical or mental health, yet even after counseling, each reiterated that abortion cannot be truly hazardous since it has been legalized. It was evident that their knowledge of abortion is very sketchy as contrasted with knowledge of contraceptives. Most of the women assume that any discomfort or pain will last for a very brief period. By the time a woman has decided to choose abortion, she is so determined and convinced that hers is a valid and good decision, that no medical arguments can sway her. Had such singlemindedness of purpose been applied to using contraceptives, there would be no need to terminate a pregnancy. Today the social problem of abortion is not only manifested by the number of abortions being requested, but primarily by the fact that abortion is passively being accepted as an alternative. Social institutions must educate society better, so that it becomes clear that abortion is not another means of birth control. (Summaries in ENG, RUS).
The Institute of Gynecology and Obstetrics in Poznan conducted a survey of the husbands of patients requesting an abortion during 1974, receiving 212 fully answered questionnaires. 38.6% were between the ages of 25 and 29. 25% had finished primary school, 36.3% vocational school, 30.7% high school and 7.5% higher education. Half were married less than 5 yrs; 16.9% less than 2 yrs. 31.1% of the couples had 1 child and 48.1% had 2 children. Many of the husbands (63%) had reluctantly agreed to their wife's abortion, expressing concern over harmful side effects. Despite their availability, contraceptives are not widely used in Poland. 39.9% families practice no birth control; while with the 56% who do, coitus interruptus and the calendar method are most frequently used. In the youngest group, 20-30 yrs, very few wives practice birth control, instead the husbands (40%) use contraceptive sheaths, reluctantly and irregularly. Men indicated that they reserve the use of sheaths for casual encounters, as a safeguard against infection. 59.9% of the husbands questioned refused to consider a vasectomy on the grounds of inhumanity and fear that it would change their sexual attitudes toward women. Older couples had serious reservations about all types of contraceptives. 55.7% felt responsible for their wife's pregnancy yet admitted to a total ignorance of female contraceptives. Based on questionnaire results, the authors conclude that husbands consider birth control to be their wife's responsibility, yet expect sexual fulfillment on demand. The fact that many wives in the survey had had more than 1 abortion reflects an egotistical male attitude and a low level of sexual culture which should generate comprehensive sociological studies. (Summaries in RUS, ENG).
Legal abortions have reduced the number of miscarriages by 20%, and of abandoned children by 56%; but at the same time, can be hazardous to the mother both initially (loss of blood, punctured uterus, damaged cervix) and later (infections in the reproductive system, infertility, extrauterine pregnancy, psychological disorders). From 1968 to 1975, 12,795 mothers and their newborns were studied: group 1 (24.8%), were mothers who have had abortions prior to 1st delivery; group 2 (42.3%), mothers having a first delivery with no previous miscarriages or abortions; and group 3 (32.9%), mothers of 2 or more children who had abortions afterwards. Abortion prior to first delivery increased the number of complications (54.4%) during pregnancy (liver and kidney problems, bacterial and viral infections), and during delivery (dirty amniotic fluid, bag of waters ruptured prematurely, pathology of the placenta and membranes, pathology of the umbilical cord). 10% of the deliveries where the mother had a previous history of abortion required medical intervention. Intrauterine dystrophy had occurred in 17% cases and the incidence of premature births was greater, 16%. 29.2% of the infants were in poor condition at delivery according to the Apgar scale (under 4 points) and 42.4% manifested disturbances in environment adaptability. The neonatal mortality rate 6.6% was twice that of the infants from the other 2 groups. The authors conclude that abortions are a threat to the health of mothers and during subsequent pregnancies, endanger the fetus and the newborn. Abortion cannot be regarded as a means of family planning. (Summaries in RUS, ENG).
The treatment of missed abortion by high dosage Syntocinon intravenous infusion.
The attempt was made to determine the reliability of high dosage Syntocinon infusions in the treatment of missed abortions and to determine undesirable side effects. 30 women who were admitted during the 1959-1961 period to the National Women's Hospital in Auckland, New Zealand with a diagnosis of missed abortion were treated with high dosage Syntocinon drip. Treatment was successful in 27 cases and unsuccessful in 3 cases, 1 of these being a normal pregnancy wrongly diagnosed as missed abortion. Severe water intoxication was induced in 1 patient. Subsequently, Syntocinon was shown to be anti-diuretic in all cases investigated. Neither adverse cardiovascular reactions or impaired blood clotting powers were noted. This form of treatment appears to be highly effective in missed abortions where the uterus exceeds the size of a 10-week pregnancy. With simple precautions taken to prevent excessive water retention, it is a safe procedure.
Delayed reproductive complications after induced abortion.
A study was undertaken to compare the outcome of a pregnancy subsequent to an induced abortion with a pregnancy subsequent to a delivery. The study was aimed at answering the question as to whether a woman who chooses an induced abortion runs a greater risk with respect to her next pregnancy than a woman who delivers normally. 619 women who aborted were compared with a sample of women matched for both age and parity who had continued with the pregnancy to delivery. Complications in the next pregnancy which were studied are: 1st- and 2nd-trimester miscarriages, cervical incompetence, premature delivery, ectopic pregnancy, and infertility. The total complication rate for the abortion group was 24.3%, and 20.2% for the control group; this difference was not significant. There were 9.1% of early spontaneous abortions in the abortion group and only 3.6% in the control group. Most of the other late complications were slightly, but not significantly, more frequent in the abortion group than in the control group. The only significant finding was a much higher complication rate among aborters who had never delivered previously. It is concluded that, except for the nulliparous woman, induced abortion carries no risk as to the next pregnancy.
Trends in attitudes toward abortion: 1972-1976.
Analysis of data from the National Opinion Research Center's General Social Survey conducted annually from 1972-76 revealed trends in attitudes toward abortion. The following 6 questions were asked. Should a person obtain an abortion if: 1) there is chance of defect in the baby; 2) a woman doesn't want any more and is married; 3) if the woman's health is jeopardized; 4) if the family has a low income and cannot afford any more children; 5) if she becomes pregnant because of rape; or 6) if she is not married and does not want to marry the father. The overall trend showed an increase in approval for each of the 6 reasons for an abortion. There was an increase by 3 percentage points for each of the traditionally hard line reasons: health, rape, and defect; and an increase of 3, 6, and 6 percentage points respectively for the soft line reasons: poor, single, and no more. In 1972 males were more approving of abortion than females; 1976 saw an increase in approval for men. There was more disparity between the sexes in 1976 than in 1975. Protestants were consistently more liberal than Catholics. Protestant increases in approval exceeded Catholic increases for rape and defect for males, and health for females. The only decrease in approval of abortion for 1972-76 was for male Catholics for rape, -3 percentage points.
The widespread practice of female circumcision in Africa is opposed by some women's groups, specifically the Women's Federation of Upper Volta and a private group of the OECD staff in Paris, but their opposition is not supported by the government. An educational campaign was launched in Ouagadougou with a series of 52 educational radio talks but the programs were stopped by the government. According to Dr. Jean Taoko of the Yalgado Hospital in Ougadougou, 70% of women admitted are excised. Many women need 2 episiotomies, a cut above and below the vagina, to be able to give birth. They have been almost closed up by infibulation after circumcision. It is hoped that respected international organizations, e.g., WHO and UNICEF, will be able to bring enough pressure to bear on African governments to relieve the problem of female mutilation.
Changing attitudes toward abortion.
Medical attitudes towards induced abortion have varied widely in the recent century as have public attitudes. Induced abortion was accepted as a matter of course, but not much discussed, in both North America and Western Europe at the early part of the 19th century. The manner in which the antiabortion movement succeeded in getting abortion prohibited in every state in the United States by 1900 is discussed. The movement was fueled by restrictive trade practices within the medical establishment and daily sensational newspaper stories of abortion abuses; church leaders were not very involved. Abortion was declared illegal exactly when the need for it was greatest; the move toward smaller families was growing. The recent British and American move toward abortion law liberalization is summarized. Initial attitutes in the U.S. were more conservative than in Britain, but they have changed more rapidly. Doctors did not participate in the repeal movement in England. They did, however, resist efforts to undo the liberalization a decade later. Physicians played a larger part in the repeal efforts in the U.S. at the state level before the Supreme Court judgment in 1973. General public opinion in the U.S. seems to be moderate on the issue of abortion with strong pro- and antiabortion voices remaining rare. The movement for a return to restrictive legislation on abortion is an affluent movement. There is no similar effort in the developing countries.
The natural family planning methods of ovulation and sympto-thermal are advocated, and the many advantages which ensue from using these methods are described. The author interviewed individuals throughout the U.S. who teach or use these methods and who provided information on their personal experience with natural family planning. In the ovulation method, women routinely look for changes in cervical mucus and use these changes to pinpoint fertile and infertile days. In the sympto-thermal method, women rely on changes in basal body temperature along with other symptoms, such as back pain and mucus changes. In artificial forms of contraception, women are forced to assume most of the responsibility for carrying out the method. In natural family planning husbands and wives share this responsibility, due to the need to abstain from intercourse several days each month. Couples who practice these methods frequently report that abstinence enriches their marital relationship and enhances sexual enjoyment when intercourse does occur. These methods of family planning permit women to detect irregularities in their menstrual cycles since body changes are monitored each month. Studies report failure rates for these methods ranging from .03-26.0 pregnancies/100 woman years of use. These marked variations in the failure rates probably stem from differences in the way the method is taught. Couples should learn about the method from competent instructors and not through the use of self-teaching manuals. Couples who practice the method themselves make the most effective teachers.
[The interaction between legalization of abortion and contraception in Denmark (author's transl)]
Trends in fertility, abortion, and contraceptive practice in Denmark were analyzed, using previously compiled official statistics; the conclusion was drawn that easy access to abortion may contribute toward a decline in contraceptive practice depending on the level of contraceptive practice in the population and on the degree of confidence the population has in available contraceptive methods. In October 1973 Denmark passed a law permitting women to obtain free abortion on demand. The number of legal abortions increased from 16,500 in 1973 to 28,000 in 1975. This marked increase was not attributable to a decline in illegal abortion since that annual number had declined from 5,000 to 1,000 prior to the passage of the 1973 abortion on demand law. The increase in abortion observed from 1973-1975 was accompanied by a marked decrease in the number of oral contraceptive cycles sold. Annual sales decreased from 3.9 million cycles to 2.6 million. It was difficult to access the factors responsible for this decline. Although IUD insertions increased during this period, the increase could not adequately compensate for the reduction in oral contraceptive sales. The decline in oral contraceptive sales occurred at about the time the negative side effects associated with the pill received widespread news coverage. Some of the decline in pill usage was probably due to fear of side effects, but abortion availability also encouraged women to be more lax about taking the pill and encouraged them to rely on less effective methods of contraception. Tables provide data for Denmark in reference to: 1) number of legal abortions and the abortion rates for 1940-1977; 2) distribution of abortions by season, 1972-1977; 3) abortion rates by maternal age, 1971-1977; 4) oral contraceptive and IUD sales for 1977-1978; and 5) number of births and estimated number of abortions and conceptions, 1960-1975.
Abortion: legal, medical and social perspectives.
In an effort to understand what is happening in the United States as a result of legalizing abortion, 3 major aspects of the issue must be examined: the legal question, the health aspects, and the psychological and sociological consequences. The legal question in terms of the cases Roe v. Wade and Doe v. Bolton are reviewed. Antichoice advocates do continue to enjoy limited success in the legislative sphere, but prochoice advocates have managed to preserve the cause of reproductive freedom in the courts. In making appropriate referrals of abortion clients, it is important to be aware of several medical issues: 1) legal abortion is safe; 2) the earlier a patient is diagnosed and has an abortion, the safer is the procedure; 3) vaginal procedures are safer than instillation procedures or hysterectomy or hysterotomy; 4) 96 % of the women who have a medically competent vaginal procedure prior to the 12th gestational week have no complications; 5) most diseases seen in women who apply for abortion do not interfere with ambulatory performance of a vaginal abortion; 6) the counselor or referring agency needs to be aware of the competence and skill of the physicians at the factility to which patients are referred; and 7) most postabortal complications are minor and can be dealt with on an outpatient basis by skilled and sympathetic medical personnel. Whatever negative consequences may result from a legal abortion, they are substantially less than those resulting from an illegal abortion. There are several factors affecting, to varying degrees, a woman's emotional reactions to an abortion. Grieving and a sense of loss are quite common, natural reactions.
Birth control and family planning in Hungary in the last two decades.
Birth rate reached its lowest point in Hungary in 1962 with 12.9/1000. In 1965 it was 14.8/1000, still under the level required to ensure replacement of the population. In 1973, population policies were started to encourage a higher birth rate, such as state benefits or family allowances to numerous families. Still, in 1978 the birth rate was only 15.7/1000 and a further decrease is expected until 1982. Between 1958 and 1977 six surveys were conducted in Hungary on fertility and birth control. Abortion was legalized in 1956, mainly with the purpose of avoiding the health impairment caused by illegaly induced procedures. The number of abortions increased until 1969, and then decreased. Data show that abortion rate among married women decreased 50% during 1957-1978, while, during the same period, it more than doubled among unmarried women. In 1958 contraception was practiced by 21% of the female population, but the percentage had increased to 52% in 1977. The pill is now used by 1/5 of women between 17-49, and it is by far the most popular method of contraception, especially among younger women. A survey conducted in 1977 shows that 80% of women plan the number of children before getting married; 2 children is considered to be the ideal family size.
Correlation between the spermicidal activity and the hemolytic index of certain plant saponins.
The attempt was made to evaluate some plant saponins for their spermicidal efficiency and to correlate this efficacy with the hemolytic index of each saponin. Testing was also done for irritant behavior of these saponins and the formulation of the most effective and least irritant 1 for semisolid application. Of the tested saponins, Gypsophila paniculata saponin was found to be the most effective on human sperms. This efficient spermicidal activity was associated with a high hemolytic index and low irritant behavior. The data obtained showed a correlation between the values of the hemolytic indices and the spermicidal activity of all the plant saponins except that of Terminalia horrida. (Summary in GER)
[Prolactin and post-pill amenorrhea (author's transl)]
10 patients on combined oral contraception (OC), with ethinyl estradiol and d-norgestrel, were observed to examine prolactin levels during each day of one menstrual cycle. At the end of treatment 4 of the patients underwent a test with thyrotropin-releasing hormone (TRH). The same test was conducted on 7 additional patients affected with postpill amenorrhea. Prolactin level appeared to be normal during OC treatment, and after termination of OC treatment. However, 3 out of the 7 additional patients examined presented a very high prolactin response to stimulation with TRH. (Summaries in ENG, FRE)
[Post-pill amenorrhea (PPA): analysis of the literature and clinical contribution]
This article presents a detailed evaluation conducted by the authors on the voluminous literature regarding postpill amenorrhea (PPA). It is evident that opinions and conclusions on the etiology, epidemiology, and endocrinology of PPA vary sensibly, according to the authors. For example, some authors state that, independently from duration of treatment, ovulation reappears in 98% of users within 3 months from termination of treatment, i.e. the rate of PPA is not above 2.2%. Some other authors state, on the contrary, that PPA appears in about 10% of women who have terminated oral contraception (OC). It must be remembered that psychological and emotional factors play a very important role in the appearance or disappearance of PPA. The article also presents 10 cases personally surveyed by the authors, in which PPA seemed to suggest a diencephalic block with different degrees of functional harm. (Summaries in ENG, FRE, GER)
Fetal crown-rump length and biparietal diameter in the second trimester of pregnancy.
This study was undertaken to assess the usefulness of crown-rump length (CRL) and of biparietal diameter (BPD) in determining gestational age in a group of patients undergoing elective abortion by intraamniotic instillation of hypertonic saline. The distribution of gestational age as reported by the patients and as estimated by the physicians were significantly different, agreeing exactly in only 1 out of 5 cases, agreeing within 2 weeks in about 2/3 of cases, and differing by more than 4 weeks in about 1 out of 6 cases. BPD can be used to predict gestational age within 2 weeks, and CRL can be used to predict gestational age within 3 weeks. Of these 2 measures, sonographic measurement of BPD has the advantage of being measurable in utero, thereby providing information which may be helpful in the clinical management of the patient.
In a letter objecting to termination of pregnancy in lieu of destructive mothering, abortion is viewed as a destructive act when a pregnancy is terminated because it was not planned. Although birth control is supported, abortion should not be used because a child would inconvenience the parents. In addition, if children were accepted, regardless of whether the child was planned, there would be a reduction in child abuse.
The effect of Ibuprofen on the intrauterine pressure and menstrual pain of dysmenorrheic patients.
12 dysmenorrheic volunteers (average age, 28 years) were studied after treatment with Ibuprofen, a nonsteroidal antiinflammatory agent. Intrauterine pressure was recorded after either placebo or Ibuprofen oral administration. 800-mg doses were used. The therapeutic action of this prostaglandin inhibitor was highly significant in reducing resting pressure (P<.001), active pressure (P<.001), and frequency of contractions (P<.05). In addition, menstrual pain was significantly reduced (P<.05). The success of this single dose of 800 mg makes feasible a more comprehensive clinical trial of Ibuprofen's therapeutic effects.
Isaptent: a new cervical dilator.
The development of a new cervical dilatator, Isaptent, from granulated Plantago ovata seed husk, is described, and results of a multicentered clinical trial for its use in medical termination of pregnancy are presented. 21 centers participated with a patient load of 804 women. The Isaptent, 3.5 mm in diameter and 6-6.5 cm long, contained seed husk powder and microcrystalline cellulose (mucilagenous matter) in the vaginally inserted tent. Of 750 subjects, a single tent resulted in satisfactory dilatation of the cervix in 95% of cases. Degree of dilatation had no relation to age, parity, or gestation period. Cervical damage was unnoticed, possibly because the tent's self-lubricating properties prevented it. Randomly selected patients were given a battery of bacteriological tests to determine changes in vaginal flora, but none was found. The Isaptent seems appropriate for labor induction and cervical dilatation because of its relatively atraumatic mechanism of action.
A placebo-controlled study of 6 dysmenorrheic women (3 single-blind and 3 double-blind) investigated the usefulness of therapy with naproxen sodium, a potent inhibitor of prostaglandin (PG) synthesis. To this end, PGs were assayed in both the menstrual blood (via cervical cap collection) and in uterine jet-wash specimens. The women were treated during 2 consecutive menstrual bleedings, once with placebo and once with naproxin sodium. Active treatment consisted of 3 doses of 550 mg of naproxen sodium. Subjective interpretations of pain were requested periodically. PG measurements revealed that both PGF and PGE were 30-400 times more concentrated in menstrual blood than in uterine jet-washings. Menstrual blood PGF concentrations of placebo-receiving patients were significantly reduced after treatment with naproxen sodium (P=.03). Average reduction in PGF was from 227-42 ng/ml, whereas for PGE it was from 10.8-3.4 ng/ml. Similarly, naproxen sodium therapy significantly reduced PGE concentrations (P=.03), whereas PGF reductions only bordered significance (P=.06). Subjective pain intensity increased insignificantly under placebo treatment, whereas during naproxen sodium treatment, pain intensity decreased from a pretreatment value of 2.5-1.3 before fitting of the cervical cap. This trial reinforces the connection between PGs and dysmenorrheic pain.
Prostaglandin biosynthesis inhibitors and endometriosis.
The possible role of prostaglandins (PGs) in the biochemistry of endometriosis prompted this placebo-controlled double-blind trial evaluating the effect of PG-inhibitors on symptoms of endometriosis (especially pelvic pain). The 4 drugs used were: 1) placebo, 2) acetylsalicylic acid (ASA), 3) indomethacin, and 4) tolfenamic acid. Each drug was administered orally from Day 20 of the menstrual cycle until end of menstruation for 2 consecutive cycles. During menstruation, tolfenamic acid (P<.01) and ASA (P<.05) lowered the endometriosis score from the pretreatment level. Tolfenamic acid was more effective than placebo (P<.05), whereas ASA and indomethacin did not differ from placebo. Each treatment, including placebo, lowered the endometriosis score (P<.05) during the menstrual period, but none of the PG inhibitors was more effective than placebo (P<.05). According to patient's subjective judgements, tolfenamic acid alleviated symptoms more effectively than other drugs tested. Pain symptoms occurred less often during tolfenamic acid and ASA than during placebo or indomethacin (P<.05). Gastrointestinal side effects were more common with indomethacin and ASA (P<.05). Indomethacin treatment raised the incidence of psychic complaints over those with ASA or placebo (P<.05). Side effects were fairly evenly distributed among the therapies.
The relief of primary dysmenorrhea by ketoprofen and indomethacin.
Ketoprofen and indomethacin were compared as specific therapies for primary dysmenorrhea in this study involving 23 primary dysmenorrheic women; the study was double-blind and cross-over. Each patient was given a code-numbered package of capsules of ketoprofen (50 mg) or indomethacin (25 mg); medication (1 capsule 3 times daily) was started 1 day before menstruation and was continued until cessation of dysmenorrheic symptoms (no longer than 4 days). Patient estimation of the effect of ketoprofen was ranked as good in 70% of cases, moderate in 18%, and nil in 12%. For indomethacin, the figures were 58, 31, and 10%, respectively. Initial dysmenorrhea score of 9.6 was reduced to 3.6 during ketoprofen therapy and to 4 with indomethacin (P<.001). Ketoprofen alleviated pelvic pain in 84% of cases; indomethacin in 78%. Mean duration of pelvic pain was reduced to 5.1 hours from an initial period of 10.6 hours with ketoprofen and 5 hours with indomethacin (P<.01); this statistic excluded cycles of total relief. Other symptoms relieved were similar with both drugs, including: lower back pain, vomiting, diarrhea, and dizziness (alleviated in 82-97%) and headache, fatigue, and nervousness (alleviated in 40-67%). Blood loss was subjectively estimated to decrease in 42% and increase in 4% of ketoprofen-treated patients, whereas for indomethacin these figures were 36% and 7%, respectively. All side effects were mild. The rate of lost working days was significantly decreased under both treatments.
A long campaign: Poland/Czechoslovakia.
The birthrates in the countries of Poland and Czechoslovakia began to decline in the 1950s. The decrease in Poland was stimulated by the government's recognition of the need for birth control. In contrast, the government of Czechoslovakia was not prepared to take a stand on birth control measures, despite the concern about the increasing abortion rate. Induced abortion was legalized in 1956 in Poland and in 1958 in Czechoslovakia, alleviating the immediate problem of illegal abortions. Legal abortions on social grounds increased 5-fold, and in the Czech regions increased from 32.1% of all pregnancies in 1958 to 40% in 1960. The situation remained unsatisfactory. To Poland's state family planning organization, the new law in Poland meant the need to defend the law against attack from the Church and to fight against abortion as an emergency exit. Czechoslovakia suffered badly from the lack of family planning groundwork. The oral contraceptive (OC) and the IUD were not introduced in Czechoslovakia until 1965 and, while it was available earlier in Poland, both countries are limited by only having a few high-dosage varieties to offer. Czechoslovakia's major drawback, compared to Poland is the lack of actual clinics. The biggest contention surrounding Czech policy on abortion focuses on the actual means of allocating terminations, a procedure that is said to lead many women to taking the illegal route. In 1973 the abortion law in Czechoslovakia was tightened up, and inducements were made to encourage couples to have more children. The Polish government also changed its policy to 1 of pro-natalism because of increased pressure from the Church and a declining growth rate.
Preoperative cervical dilatation with 15(S)15-Methyl PGF2alpha methyl ester pessaries.
A clinical trial comparing 2 vaginal dose schedules of 15(S)15-methyl prostaglandin F2alpha (PGF2alpha) methyl ester (4 or 6 mg) for preoperative dilatation is described. The trial included 28 patients at 8-12 weeks gestation. Vaginal pessaries containing either 1.0 mg (15 patients) or 1.5 mg (13 patients) of the prostaglandin analogue were administered every 3 hours (maximum, 4 doses). The success rates for the 2 groups were 93% and 10% respectively. A 96.4% overall success rate is comparable to that achieved in other studies. 60% of the patients aborted before the planned vacuum aspiration. Minor side effects, primarily vomiting and diarrhea, occurred in approximately 80% of the cases and were more prominent with the higher dose pessary. Since this higher dosage produced an unacceptably high occurrence of gastrointestinal side effects, the lower dosage of < 4 mg is preferable. It is concluded that vaginal administration of 15(S)15-methyl PGF2alpha methyl ester is highly effective for preoperative dilatation of the cervix before suction curettage abortion. (Authors' modified)
Serial intramuscular injections of 250 mcg of 15(S,15-methyl-prostaglandin F2alpha were given to 105 women every 1-3 hours in an attempt to induce second trimester abortion (N=80) or labor (N=25). Patients were divided into 5 groups: those with missed abortions; those with pregnancy terminations; those with molar pregnancy; those with intrauterine death; and those where labor was induced with a live anencephalic fetus. The treatment was highly successful; the cumulative expulsion rates at 12 and 24 hours were 69% and 95% respectively. There were no serious complications, and significant alterations in the mother's vital signs were uncommon. Gastrointestinal side effects are tolerable if the woman is properly premedicated and maintained on the antiemetic, antidiarrheic, and analgesic treatments. (Authors' modified)
Several demographic sample inquiries have been conducted in African territories formerly administered by France. As a result of the fact that the data were collected with similar objectives and procedures and controlled by statisticians and demographers drawing on a common body of experience, the records have been collected and tabulated in the different areas in much the same form. The similarities make it convenient to treat the studies of these territories as an integral whole. The records analyzed were from sample inquiries covering the countries of Guinea (1954-1955), Upper Volta (1960-1961), Dahomey (1961), and parts of territories. A relatively small section of the records collected will be utilized, partly because the objective is to estimate the basic demographic measures of fertility, mortality, and growth as accurately as possible and partly because of the gaps in the information in these areas. All the surveys were sample inquiries in which the fundamental unit was the household. The primary data for the estimation of fertility and mortality are of 2 types, denoted by the terms "current" and "retrospective." Each section is arranged in subsections which deal with fertility, mortality, reproduction, and age distribution.
Survey of laws on fertility control: country profiles.
This monograph is a summary of the laws on sterilization and abortion for fertility control purposes in 140 different countries. Emerging trends in sterilization laws are: 1) a recognition of the right of mature individuals to the operation on request; 2) protection of younger persons against premature decisions by a requirement of committee authorization; and 3) requirement of an informed and free decision to maintain voluntarism. Laws dealing with induced abortion in recent years have moved in the direction of liberalization in most parts of both the developing and the developed world. It is hoped that this compilation of laws will be useful for researchers, health and family planning administrators, and legislators working on similar legislation for their own countries.
[Juridicial aspects of family planning]
The legal aspects of birth control in Brazil are, to say the least, complex and confusing. Family Planning can be seen from a religious, political, medical, and social point of view, beside a juridical one. Juridical aspects can be related to constitutional law, labor law, and to administrative, civil, and penal codes. There are in Brazilian law inherent limitations to family planning. Some of these limitations are: 1) the existence of a salary for large families. This salary, instituted to help numerous families, does in fact encourage couples to have more children than they can support; 2) a pregnant and nursing mother can leave her job for as long as 4 months and even longer without taking a cut in salary; 3) abortion is legal only when induced to save the mother's life. This means an average of 1,500,000 illegal abortions a year; and, 4) sexual sterilization and contraception are legal only when prescribed by a doctor.
The attempt is made to provide some answers on the use of Depo Provera. In the use of Depo Provera, the standard procedure is to give an injection of 150 mgs in 1 ml in an arm or hip muscle every 12 weeks, beginning soon after delivery or miscarriage or early in the menstrual cycle in the case of menstruating women. The outstanding attraction of the long-acting contraceptive injection in the minds of the 81,034 Chiang Mai acceptors is what can be described as the freedom from the fear of forgetting. The acceptors also enjoyed the ease and convenience of administration and the high effectiveness of the method. Of 142 women using this method for a year, on an average, only one woman will have an unexpected pregnancy. Depo Provera has a lower failure rate then IUDs, condoms, foams, jellies, or the "safe period," and it does not produce pelvic infection and inflammation wometimes seen with IUDs. It also does not effect breast milk in nursing mothers. The drawbacks to the use of the injectable contraceptive include amenorrhea, irregular menstrual periods, spotting, and sometimes heavy periods. Depo Provera also has other uses which include use in instances of threatened and habitual miscarriage and use in the treatment of endometriosis. Depo Provera is a safe method. Among the estimated 1 million or so users, there has not been a death caused by Depo Provera. Depo Provera has been approved for use in 10 European countries. The World Health Organization and the International Planned Parenthood Federation have approved the use of Depo Provera.
[Blood coagulation disorders in the course of interrupted advanced pregnancy]
In some countries abortion may be done legally up to the 24th week of pregnancy. In Poland the legal limit is 12 weeks except for such cases which medically require termination. The methods most often used to terminate an advanced pregnancy are: introduction of a sharp agent like sodium chloride, glucose, ryvabol or urea into the uterus, introduction of a rubber tube between the uterine wall and the fetus, and use of prostaglandins. The latter is the preferred method, but because prostaglandins are expensive and not easily available, doctors everywhere are forced to resort to the other methods. (Glucose is one of the weaker and less effective agents). A 20% hypertonic saline solution usually induces intense uterine contractions that eject the fetus within 30 hrs. In 1968 Wagatsuma reported 13 deaths in Japan following hemorrhaging which occurred with this method. Standen in 1971, noted consumptive coagulopathy, a decrease of fibrinogen Factor 5 and 8. Sodium chloride breaks down the thromboplastin in the placenta which then enters the mother's blood stream. Usually the process returns to normal without medical intervention if there is no threat of hemorrhage. The saline solution, however, should not be used in women with plasma-platelets diathesis nor on those who have a kidney or heart problem. The safer procedure in those cases is to use prostaglandins i.e., 10mg PGE2 or 50mg PGE2a in 1 dosage, causing the fetus to be ejected after 20 or 30 hrs. Many doctors use oxytocin with prostaglandins, thus reducing the amount required of the latter. Neither oxytocin, glucose, nor urea have a harmful effect on coagulation. (Summaries in RUS, ENG).
[Extraamniotic induction of abortion with a new prostaglandin E2 derivative]
31 patients underwent induced abortion and 7 patients underwent treatment for missed abortion by intrauterine extraamnial instillation of the prostaglandin E2 derivative SHB 286. A single instillation of 50 mcg or 100 mcg SHB 8286 was administered via catheter without cervical dilatation in a saline solution according to the impact method. 2/3 of the patients received 100 mcg instillations of SHB 286; the average induction-abortion interval was 4 hours shorter than for those who received 50 mcg installations. Multigravidae had shorter induction-abortion intervals than others who received the same SHB 286 dosage.96% of the a patients underwent abortion within 24 hours after instillation; in the remaining cases mechanical cervical dilatation was easily effected. There were no complications. (Summary in ENG)
Repeated abortion seeking behavior is common among the population of Vojvodina, Yugoslavia, and the number of abortions a woman undergoes often reaches into 2-digit figures. A study sample was drawn from the population of women who came to the Department of Obstetrics and Gynecology of the University of Novi Sad Medical School. There were 72 women randomly selected from those seeking abortion, and 72 women randomly selected from those seeking contraception. Although both abortion and contraception are easily available and equally accessible, abortion is a widespread and generally socially acceptable practice while modern contraceptives are insufficiently used despite encouragement of their use. When exposure to risk was considered, the abortion group had abortions at about twice the frequency of the contraceptive group when exposure to risk was taken into account. The highest percentage of women of the population surveyed began their fertility history with a delivery. After that a 2nd delivery (pattern 1) or abortion (pattern 2) most frequently followed. In the same number of women of both groups at the beginning of the fertility history (9 of 72), unwanted pregnancy terminated by abortion occurred. Abortion occurred either as unplanned pregnancy at the beginning of the fertility history (patterns 4, 5, and 6) or, much more frequently, as the 2nd fertility event (pattern 2). The total number of abortions in both groups, taking into consideration the first 3 fertility events, was nearly the same. The data indicate that women in the contraceptive group have gradually adopted contraceptive means and managed to reduce the number of unplanned pregnancies.
Pregnancy termination combined with sterilization.
There are several factors favoring sterilization performed concomitantly with abortion. Abortion combined with sterilization is both an acceptable and widely practiced technique. The choice of the sterilizing procedure varies with the duration of the pregnancy, skill of the surgeon, availability of treatment facilities, and presence of other coexisting gynecologic or medical problems. In the 1st trimester of pregnancy, minilaparotomy, posterior colpotomy, and laparoscopic sterilization provide viable and acceptable methods of achieving sterilization. Minilaparotomy and posterior colpotomy are the preferred methods in the 2nd trimester unless laparoscopy is performed by a skilled laparoscopist. Hysterectomy appears to be a reasonable procedure when there is adequate indication for this major surgical procedure. Hysterectomy should be performed only if the patient understands that increased morbidity and complication rates exist for this major procedure as opposed to the complication rates for lesser combined procedures. If clinical judgment requires a delay in performeing the sterilization procedure for safety reasons, then interim sterilization should be elected. Contraception counseling is a necessity if the patient chooses to delay the sterilization, since ovulation may occur before 1st menses after abortion. The various sterilization procedures are described in detail.
Abortion of early midtrimester pregnancy with commercially available prostaglandins.
Prostaglandins are used extensively for inducing midtrimester abortion. The approved routes of administration, intraamniotic for PGF2x and vaginal for PGE2, though not the most convenient are the most satisfactory. Focus is on intrauterine intraamniotic administration (unaugmented intraamniotic methods, augmented intraamniotic methods, safety in clinical practice) and vaginal administration (vaginal PGE2 for midtrimester abortion, vaginal PGE2 for death in utero), and intrauterine extraamniotic administration. Clinically acceptable complication rates and induction times result when PGF2x is combined with hypertonic urea or saline. Instillation methods are safer than the major operative procedures of hysterotomy and hysterectomy for abortion. Vaginal administration of PGE2 is more convenient than intraamniotic techniques in cases of death in utero and hydatidiform mole when dilatation and evacuation is impractical. Clinically acceptable delivery rates and side effects occur. Disseminated intravascular coagulation and uterine rupture will continue to be a problem in patients with death in utero. The approved prostaglandin methods for induction of midtrimester abortion have severe limitations. Better methods of midtrimester abortion with prostaglandins will depend upon better delivery methods and/or prostaglandin analogues with better therapeutic ratios. The extraamniotic administration of prostaglandin is not approved for use in the United States but is approved in other countries.
The use of hyperosmolar urea for the elective abortion of midtrimester pregnancy.
The protocols and procedures relating to the use of hyperosmolar urea in combination with either intravenous oxytocin or intraamniotic PGF2x for midtrimester abortion at Johns Hopkins Hospital (Baltimore, Maryland) are summarized. All patients for midtrimester amnioinfusion undergo a careful history and physical examination. discussion is based on 1913 cases contained within a recent report and an additional 199 cases utilizing 5 mg PGF2x for augmentation. The mean age of patients was approximately 20 years; 60% of the patients undergoing urea infusion were teenagers. For the total groups, the differences in interval between urea-PGF2x (5 mg) versus urea-oxytocin and urea-PGF2x (10 mg) were significant. The difference between urea-oxytocin and the urea-PGF2x (10 mg) was also significant. No live fetal abortions occurred within the series. With the evolution of reduced doses of PGF2x, the failure rate has shown a gradual decline, while the rates for incomplete abortion have undergone considerable change. There are several advantages of hyperosmolar urea in comparison with either intraamniotic hypertonic sodium chloride or PGF2x. Urea readily crosses cell membranes and is an osmotic diuretic so that there is less concern in instances of inadvertent intravascular injection. 1 problem is that augmentation is required in order to achieve injection-abortion intervals of less than 24 hours. The rate of incomplete abortion makes it necessary that physicians adept at removal of retained placenta with intravenous analgesia be readily available. Complications such as hemorrhage, infection, and gastrointestinal problems are, in general, readily managed from a clinical standpoint. The most troublesome complication appears to be cervical laceration.
Discussion summary [of late midtrimester pregnancy termination] .
The controversy as to how best to terminate a pregnancy becomes more intense the further into the 2nd trimester a pregnancy has progressed. 1 participant in the discussion of late midtrimester abortion felt that the actual cervical laceration rate with the intraamniotic techniques may be higher than commonly reported, and for that reason he has abandoned the use of hypertonic saline with prostaglandins. A study was described in which 600 patients received intramuscular injections of 250 mg 15-methyl PGF2x at 2-hour intervals for late midtrimester abortion. In the first 150 patients, this dosage schedule yielded a success rate of 94%, with 75% completions. In an effort to reduce the mean instillation instillation-to-termination time and increase the success rate, 1 medium-sized laminaria was inserted just before the 1st injection. The success rate was not improved and the time was not shortened. When laminaria were inserted 18-24 hours before the 1st injection, the mean instillation-to-termination time was markedly reduced and the success rate increased to 99%. There were a large number of gastrointestinal side effects, but these were not particularly troublesome to patients. Complications consisted mainly of infection. It was observed that comparisons of 1 pregnancy termination technique with another when based on sequential kinds of experience are not always useful, and a controlled collaborative study of the various commonly used methods has yet to be conducted. Several participants expressed a willingness to participate in such a collaborative study. The question was raised as to whether previous cesarean section is a contraindication for hypertonic saline inductions.
Medical indications for pregnancy interruption.
Current legislation restricting state and federal funding for abortion means that medical conditions possibly resulting in death or "severe and long lasting physical health damage" must be reassessed at this time for those cases in which public funding is involved. If abortion is designed to prevent maternal death, it is helpful to review indirect but primary causes of maternal mortality from recent years, before changes in abortion laws. Under restrictive legislation, abortions for medical reasons were not often performed. Although some of the indications were more common, a wide variety of reasons existed. The need to interrupt pregnancy because of heart disease has diminished in recent years. The most significant endocrine disease during pregnancy is diabetes, but with modern management maternal mortality is rare and the perinatal statistics are good. Tuberculosis is no longer considered an indication for abortion. Hematologic disease of some types contribute to maternal mortality. Sicke cell disease and S-C hemoglobin disease are associated with increased mortality during pregnancy. Inflammatory bowel disease usually does not change the course of pregnancy, but there is an increased rate of relapse postpartum. Data regarding maternal cancer show that it was a significant cause of pregnancy termination. The majority of cancer cases were breast cancer. Maternal neural tube defect may be severe enough to consider pregnancy termination. If the mortality statistics are to be believed, the treatment of suicide cannot often be used as justification for pregnancy termination.
Impact of restrictive abortion laws on health services.
When abortion is legalized many pregnancy terminations move from the streets to the hospital or clinic. After repeal of restrictive abortion laws in 1973 in New York the maternal mortality rate fell from 5.2 to 2.3/100,000. In Britain there has been a cecline in deaths due to abortion since the law was liberalized in 1976. Over half the world's population lives in countries where laws are liberal, which puts a strain on health care systems. Outpatient procedures and free-standing clinics are needed outside the hospital system. Private nursing homes providing only abortion services have appeared in many liberalized countries. In Santiago, Chile, where abortion laws are restrictive, 4 out of every 10 emergency room admissions are for abortion complications. In Ghana a comparative study of admissions for setpic abortion and hospital-induced abortions in Accra found that the average periods of hospitalization were 2.17 and 1.54 days respectively. In the Sudan, where abortion is permitted only for medical reasons, incomplete abortion was the main cause of admission to gynecologic wards from 1974-76 in Khartoum. A study of 2447 patients treated for incomplete abortion during this period recommended that an outpatient service be established at major hospitals; use of general anesthesia and sedatives be discontinued; vacuum aspiration methods be used; and, routine follow-up clinics be established for treatment of complications.
The health consequences of illegal abortion in Latin America.
An estimated 34% of all maternal deaths result from abortion complications. The less skillful the abortionist the higher the complication rate. Self-induced abortion complication rates are up to 100%. In Santiago between 1940-64 infant mortality rates declined over 50% but hospitalization rates for abortion complications increased by over 60%. Abortion rates have been increasing throughout Latin America; one study by Rosada found that in 1964 in Motevideo there were 3 abortions for every 5 births. A family planning program that inserted IUDs during the postpartum and postabortion periods reduced the number of hospitalizations for abortion complications in one section of Santiago by 29.4% compared to 5 years earlier. Where abortion is legal complications are almost non-existent for the first 12 weeks of pregnancy. In countries where abortion is illegal, especially in Latin America, only the very rich can afford sanitary conditions. The medical profession has a strong obligation to create better understanding of all reversible methods of contraception and help provide services that will increase use of contraception. Requena's studies show that women who have one successful abortion often repeat the practice. Steps should be taken to prevent a recurrence of hospitalization for abortion complications. If an IUD is inserted directly after the uterus is cleaned, the operation will not be prolonged by more than 2 minutes.
A practicable and reliable method for inducing labor in patients whose pregnancies are complicated by intrauterine death of the fetus is described. The method involves the intraamniotic instillation of 30 mg of prostaglandin F2alpha with 60 gm of urea. 20 patients were investigated with pregnancies ranging between 22 and 41 weeks and with the estimated duration of fetal death ranging between 2 and 8 weeks. In all cases, delivery was achieved within 24 hours. Prior to the induction of labor, plasma human placental lactogen (hPL); progesterone concentrations; and numerous blood coagulation parameters i.e., plasma fibrinogen, blood platelet count, and serum fibrin degradation products [FDP] concentrations) were measured. No statistically or clinically significant alterations occurred in the first 2 measurements, and FDP concentrations increased during labor in most patients. Side effects and complications were minimal and the induction-delivery interval was not influenced by the presence of residual viable placenta prior to induction. Thus, this method which only requires a single intraamniotic instillation is highly recommended. (Authors' modified)
[Obstetrical complications of artificial abortion]
A significant rise in the number of cervical ruptures, inflammatory states of adnexae, and menstruation disorders was observed in women who underwent artificial abortions. In those women who had several artificial abortions, a proportional rise in the number of complications was not observed. A greater incidence of operative deliveries, premature labors, and increased perinatal mortality rate were noted. In the same subjects, the number ofspontaneous abortions remained similar to that in the control group who had not undergone artificial abortion. Abnormality of the placenta was the source for the majority of perinatal complications. This was probably due to the fact that nidation occurred in the endometrium with inflammatory changes or mechanical injuries following the passed abortions. It is also likely that there exists a causative link between premature labors and vast cervical lacerations. (Authors' modified)
In a randomized double-blind study, a viscous gel, containing 0.25 mg prostaglandin E2 (PGE2 gel) or without prostaglandin (placebo gel), was applied intracervically in 22 nulliparous patients just before termination of early pregnancy by dilatation and evacuation (D & E). Within 12 hours a marked ripening of the cervix was found in the 11 patients receiving PGE2 gel. Thus a significant change in cervical dilatation from mean 5.4 mm to mean 10.7 mm occurred. The observed changes in consistency and in degree of dilatation are statistically significant (p 0.0001). Furthermore, a considerable softening of the cervix was registered. In the 11 patients receiving placebo gel, no significant changes in cervical dilatation or consistency were found. The subsequent D & E was easily performed in all patients treated with PGE2 gel. However, in 3 of the patients given placebo gel, D & E was difficult to carry out because of an unfavorable cervical state. To eliminate or decrease myometrial activity the calcium antagonist nifedipine was given orally to 8 patients at application and 5 hours after application of 0.25 mg PGE2 gel. None of the patients recognized uterine contractions. However, also in these patients significant changes in cervical consistency and dilatation occurred within 12 hours. No side effects of the treatment were observed. It is concluded that a preoperative, intracervical single application of 0.25 mg PGE2 seems to be useful to ripen the unfavorable cervix before subsequent termination of early pregnancy by D & E. (Authors' modified)
During recent years, the use of steroid anesthesia has rapidly increased. A number of surgical procedures have been performed under Althesin anesthesia, and in some cases the peroperative bleeding seemed to be rather profuse. Blood loss was studied in 90 healthy nulliparous women, ages 15-39 years, in the 1st trimester of pregnancy, undergoing therapeutic abortion with different types of anesthesia. The patients were divided into 3 equal groups of 10 persons according to duration of pregnancy. Group 1 patients underwent surgery under local anesthesia, group 2 under thiopental anesthesia, and group 3 under Althesin. Blood loss in all 3 groups was smallest when local anesthesia was used (only 1/3 - 1/2 of that occurring under thiopental anesthesia). With thiopental anesthesia, the blood loss gradually increased with increasing gestational age with only moderate variations. Alternatively, in this investigation, Althesin anesthesia was characterized by pronounced blood loss, particularly in group 2 (p 0.05) and particularly in weeks 9-10 of pregnancy. Althesin was also associated with a wide range in blood loss, especially in group 2 (40-300 ml). The occurrence of profuse hemorrhage, seen in those administered Althesin, may be hazardous to those with cardiovascular difficulty. Thus it should be used for gynecological surgery only in departments equipped to control profuse bleeding and possible cardiovascular complications. (Authors' modified)
11 mothers with intrauterine fetal death and 2 with anencephalic fetus ranging from 23 to 36 weeks gestation received 100 to 250 ug of 15-methyl-PGF2alpha intramuscularly at 2-4 hour intervals to induce labor. The mean delivery time was 7 hours (ranging from 45 minutes to 20 hours), the mean number of injections was 3.1, and the mean dose was 400 ug (ranging from 100-700 g). 10 mothers experienced diarrhea and 3 women vomited but there were no serious side effects. Parity or gestational age was unrelated to the efficacy of 15-me-PGF2alpha.
Demographic techniques in describing contraceptive use applied on the situation in Sweden.
It is suggested that the amount of contraceptive use in a female population should be expressed in the same terms used by demographers to describe fertility within that population. In this way, the relationship between levels of contraceptive usage and levels of other fertility indicators, e.g., birth and induced abortion rates, could be examined. The method was applied to data on pill and IUD usage in Sweden in the 1964-77 period. Calculation of the number of oral contraceptives consumed annually is described. IUD usage annually was calculated by combining the number inserted that year with the number remaining in utero from previous years. Changes and trends in usage of pills and IUDs in these years in Sweden can be seen in the constructed tables. The use of orals increased rapidly up to 1969, decreased from then until 1975, and then increased to approximately 230 oral users/1000 women of reproductive age. IUD usage started slowly in the late 1960's and increased steadily to the point where approximately 200 women were using IUDs in 1975 for every 1000 women of reproductive age. The curve combining pill and IUD usage shows the rapid increase in these modern methods in Sweden. It was estimated, using the newly-figured contraceptive use rates, that the total delivery rate was 1.8, the total induced abortion rate .6, the oral rate 7 years, and the IUD rate 6 years per woman in her reproductive lifetime.
The problems of therapeutic abortion and infanticide.
Medical professionals need to revaluate current ethical standards which permit the killing of a normal fetus but require the use of heroic efforts to save the life of a severely deformed or mentally handicapped child once that child is born. The ethical issues involved in both abortion and infanticide are similar. Direct objections to both of these practices refer to the person killed and indirect objections refer to the side effects experienced by the family and society. Direct objections are irrelevant in abortion since the fetus is not aware that it is being killed and are also irrelevant in infanticide until the child is old enough to become aware of death. Indirect objections to abortion include: 1) guilt experienced by the mother and the abortion provider; 2) decline in maternal feeling in the society as a whole; and 3) the use of medical personnel and facilitates to provide unnecessary services. Advantages associated with abortion are that it: 1) reduces the number of unwanted children; 2) reduces the number of abnormal children; and 3) provides a safe and inexpensive form of contraception. Indirect objects to to infanticide are similar to those noted for abortion. The advantage of infanticide is that it avoids the on-going distress of parents who must live with and support a severe handicapped child.
Husbands' attitudes towards abortion and Canadian abortion law.
In a 1975 study of attitudes toward abortion among a stratified sample of 601 men residing in Toronto and married to women of reproductive age, non-Catholic men and men who had weak religious beliefs had significantly more permissive attitudes toward abortion than Catholic men and men who had strong religious beliefs. Each respondent received a scale score based on his acceptance of abortion under 7 different conditions. The 7 conditions were: 1) threat to maternal life; 2) pregnancy due to rape; 3) predicted birth of a mentally or physically handicapped child; 4) threat to maternal mental health; 5) unmarried mother; 6) marriage breakdown; and 7) inability to financially support the child. A high score indicated a permissive attitude toward abortion. High scores were associated with high income and educational levels, non-Catholic affiliation, weak religious beliefs, and being Canadian by birth. When religious factors were controlled, the effect of the other factors was markedly reduced. No association was observed between scale scores and the variables of age and expected family size. A majority of the men approved of abortion for 5 or more of the above listed situations. Men with high scores were more likely to use effective methods of contraception, to be married to women who had abortions, and to favor less restrictive abortion laws. Non-Catholic men and men with weaker religious beliefs were more likely to favor easing the abortion law than Catholic men and men who had strong religious beliefs. Those with higher income and educational levels within each religious group were also more likely to favor easing the law. Tables show: 1) the % distribution of respondents approving abortion by reason for the abortion; and 2) the results of the analyses using various measures of association.
Uterine rupture caused by midtrimester saline abortion.
Hypertonic saline administered intraamniotically and followed by oxytocin infusion has been known to cause uterine rupture in a single grandmultiparous patient. A case report is presented on the 1st documented incident of uterine rupture following intraamniotic saline injection followed by oxytocin infusion in a patient of low parity. This uterine rupture occurred prior to expulsion of the fetus or manual removal of the placenta. The patient had experienced already a previous 1st-trimester, vaginal abortion. It is unknown whether this previous abortion had a causative effecton the abnormal placental implantation of this pregnancy, but it is certain that the abnormal implantation probably contributed to the uterine rupture. The adult respiratory distress syndrome which occurred in the case reported is consistent with intraabdominal ahemorrhage and shock. Any hypertonic saline instillation followed by unusual abdominal discomfort, orthostatic hypotension, and anemia should be investigated for the possibility of uterine rupture.
Mechanism of failed labor after fetal death and its treatment with prostaglandin E2.
The efficacy of prostaglandin E2 (PGE2) for termination of pregnancy harboring a dead fetus was studied in 65 women whose fetal death was confirmed for from 3 days to 8 weeks. An attempt to elucidate the mechanism of failed labor associated with in utero fetal death was also made, and to this end intrauterine pressure was measured through PGE2 induction of labor. Also established were dose-response relationships. In terms of mechanism of failed labor, plasma progesterone levels in pregnancies harboring dead fetuses from 12-40 weeks of gestation were lower (by 20%) than parallel levels in pregnancies with living fetuses. In addition, uterine size, as estimated from fetal birth weight, was also in the low range. It is concluded that the uterine volume/progesterone ratio is equal to or greater than that in normal pregnancy, and this, it is argued, partially explains the lack of spontaneous labor. The patients were grouped according to gestation week in increments of about 4 weeks. Uterine responsiveness could not be consistently related to progesterone levels, PGE2 dosage, or instillation-to-delivery time (IDT) within each group. Dosage requirements progressively decreased with each gestational week grouping (i.e., higher gestation) and oxytocin sensitivity. When patients were grouped into fetal death at or 2 weeks (n=25 vs. 40), no significant dosage or delivery time differences were noted. The 24-hour IDT was 92%, and the IDT of the total group was 11.2 hours. Dosages ranged from 45-22 mg/suppository as gestational time increased (i.e., from 12-41 weeks). Dose-delivery response did not correlate with age, parity, or progesterone levels, but only with oxytocin responsiveness. Three serious complications occurred and are presented as case studies within the clinical report. All of these involved hypotensive responses.
Since 1974 in Bordeaux, France, the association "Assistance for pregnant women in distress" attempts to prevent induced abortion, legalized by law in 1975. The personnel of the association, gynecologists, psychologists, and social workers, are not there to pass a judgement, but to inform, counsel, and eventually to offer an alternative to abortion. The majority of women requesting abortion are between 20-25, married, in the first trimester of pregnancy, nulliparous, and with a job. A review of the individual folders of patients assisted revealed that, aside from pathological cases, motivations for abortion were not well founded. Since abortion was legalized in 1975 it became a common occurrence; this is clearly shown by the fact that the percentage of married women requesting abortion passed from 38% to more than 58%, and that the dissuasive action exercised by the association, which exceeded 40% before the law, dropped to 8% after the law. In 3 and a half years the association was able to save only 117 new lives over 751 requests for abortion; certainly a small percentage which, however, has not discouraged the activity of the association. (Summary in ENG)
[The clinical management of post-pill amenorrhea]
Post-pill amenorrhea is arare occurrence, and is very often concurrent with galactorrhea and hyperprolactinemia. The authors of this article, after carefully reviewing the literature on the clinical management of post-pill amenorrhea, come to the conclusion that in more than half the number of cases the problem regresses spontaneously without treatment. Post-pill amenorrhea associated with anovulatory sterility can be treated with: 1) clomiphene, by carefully adjusting its administration to every single case; clomiphene usually entails an increase in the volume of the ovary; 2) pituitary or chorionic gonadotropins when the ovary is normal but inactive; 3) cortisone; there are, however, few descriptions of its use in the literature; 4) pyridoxine, which has the advantage of being extremely cheap and easy to administer; 5) bromocriptine, whose mechanism of action is still not clear. Patients who desire to become pregnant must be treated not so much for amenorrhea, but for anovulatory sterility. This can be accomplished with ovulation inductors, after checking for the presence of hypophysary adenomas. Patients who do not desire pregnancy can be treated with bromocriptine to restore the menstrual cycle, and be prescribed nonhormonal contraception. (Summary in ENG)
Between 1970-74, 134 hospitalizations were recorded in a large metropolitan hospital in France for sequelae of illegally induced abortion; there were 12 deaths. In January 1975 the law making abortion legal before 10 weeks of gestation was passed. Between 1975-77 in the same hospital only 8 hospitalizations were recorded for the same reasons; there were no deaths, and, still, 6 of these hospitalizations were, admittedly, a consequence of clandestine abortion. Such data are self explanatory. Several statistics show that 10% of women requesting abortion have passed the 10 weeks of gestation; such women must, again, either recurr to clandestine abortion, or to obtain one in a foreign country. Moreover, many physicians are still against abortion, and in a position, in many hospitals, to effectively hinder or boycott the practical and administrative procedures conducing to abortion. It would be advisable to open, within the larger hospitals, small independent centers staffed mostly by motivated personnel, and equipped to perform only abortion, and to distribute information on contraception. Better yet, it would be advisable to modify the law, so that abortion may be legal also after 10 weeks of gestation.
[Drug interaction and post-pill amenorrhea]
Post-pill amenorrhea often happens in patients who have been or are on psychogenic drugs, by influencing, together with oral contraception (OC), the hypothalamic hormones released, and interacting in the metabolism of monoaminergic neurotransmitters. Some conclusions are obvious: 1) if a patient on psychogenic drugs presents menstrual irregularities, a strict collaboration between her neuropsychiatrist and gynecologist is necessary; and 2) the use of all drugs influencing the hypothalamic system must be kept under close surveillance in women taking OC. (Summary in ENG)
Hypertonic saline amino-infusion for termination of second trimester pregnancy.
The 2nd-trimester abortion method of saline injection into the amniotic cavity is discussed. So far, the method has proven to be effective and generally applicable. Mortality associated with the method runs approximately 18/100,000; this compares with a 200/100,000 for either hysterectomy or hysterotomy. Even with proper techniques and precautions, the mortality rate could be cut in 1/2 but never removed completely. The morphologic and physiologic changes which occur as a result of saline instillation are described. The method is contraindicated for women who cannot tolerate either a normal labor or a 40g salt load. The procedure, which can be carried out in a standard treatment room environment, is described. Management Managemnt of the subsequent labor is described. Minimum special care is involved. Active intervention for placental removal will only be necessary if bleeding begins or the placenta has not passed spontaneously with 1-2 hours. Either oxytocin or laminaria insertion into the cervix may shorten the instillation-to-abortion time to an average of 23 hours, but both carry serious risk of morbidity. Complications of the procedure and recommended treatment are enumerated.
A comparison of saline and prostaglandin abortions at the Medical Center of Central Georgia.
Results of a retrospective comparison study of 2 different mid-trimester abortion methods are presented. Some variables were not controlled but the 2 study groups were similar as to age, gravidity, and gestation. Injections of either hypertonic saline or prostaglandins were used to induce abortion. Oxytocin was used sporadically with both groups and Laminaria were used routinely with the prostaglandin and occasionally with the saline group. Results are tabulated. A comparison of the differences in time from injection to abortion for the 2 groups showed a statistically significant difference at the p=.05 level. Prostaglandins produced abortions in an average of approximately 9 hours less time than saline solution. No serious complications were observed for either abortifacient. Gastrointestinal side effects were minimal for the prostaglandin group. It is concluded that prostaglandins are a safe and effective abortifacient with fewer serious side effects than saline.
A private choice: abortion in America in the seventies.
This is the 1st book to explore the legal and social implications of the 1973 Supreme Court decisions invalidating state laws regulating and restricting induced abortion. U.S. Constitutional law in general is discussed and the specifics of the 1973 Supreme Court rulings examined. The recent history leading up to the rulings, legends and myths involved in abortion policy, mass media and political interest group positions on the issue are all examined. The impact of the reinterpretation on the family, on the practice of medicine, and on the political process are observed. It is concluded by many scholarly authorities that the rulings had no foundation in Constitutional law. In fact, the enactment amounted to a judicial grab for power and unbalanced the Constitutionally-mandated balance of powers. The ruling is found to have stirred up controversy among groups within the society and to have coerced individuals whose consciences did not agree. The ruling results in violation of the right to life of the unborn child and usurps rights and liberties of other groups involved. For example, the poor are now coerced to destroy their ubornc children. The ruling must be overturned. The book includes indices of terms used and legal cases cited.
Pregnancy complications following legally induced abortion.
Both a prospective and a retrospective study were carried out to evaluate longterm consequences of a legally induced abortion. Data used for the study were taken from a WHO (World Health Organization) study of longterm sequelae of induced abortion. Both studies used Danish women and matched controls. It was found that bleeding before 28 weeks of gestation and retention of placenta or placental tissue in subsequent pregnancies occurred more frequently in women who had previously experienced a legally induced abortion. No comparison revealed an increased rate of low birth weights for subsequent births. Other pregnancy and delivery complications were not found to occur more frequently after legal abortion. The study did not establsh with certainty that the risk of prematurity is elevated following induced abortion. Previous studies of longterm sequelae of induced abortion have failed to state the type of abortion technique used. No correlation between type and later prematurity has been found.
Spontaneous abortions and terminations of pregnancy: histological differences.
Uterine curettings following 8 1st-trimester induced abortions were compared with material curetted from 2081 uteri following spontaneous abortions. The laboratory procedures are described. Polymorph infiltrate of the decidua was found in all cases of spontaneous abortion, indicating that a portion of the tissue had died at least 4-5 hours prior to the abortion. In 7 of the induced abortion cases there were no polymorphs in the decidua. The 1 case which showed polymorph infiltrate exhibited other features of degenerating suggesting that a spontaneous abortion may have been developing had the pregnancy not been terminated with an induced abortion. It is hoped that further research into this area will clarify the mechanisms involved in spontaneous abortion.
A study of change in Mexican folk medicine.
Religious beliefs have been an integral part of Mexican folk medicine which is used by medical practitioners (curanderos) and Spiritualists. Minor illnesses are usually diagnosed and treated at home using either herbal potions or modern patent medicines. But if an illness is not cured, the sick person believes that he is bewitched and requires a cure from the curanderos or Spiritualist. Modern scientific medicine is not readily accepted since it is not based on religion and therefore poses a threat to the religious and moral codes of the rural community. In addition, doctors are not always available since they are usually located at some distance from the community. Curanderos take a personal interest in each patient and treat them in their own homes for a nominal charge. Spiritualists are popular since they offer treatments for diseases caused by witchcraft, which is a major social problem in rural areas.
A symptom not a cause: France.
In France there are more births than anywhere else in Europe. People produce children by desire, not by instinct. In a consumer society it is increasingly difficult to raise children because of the spiralling costs. Repressive laws existed in France between the 2 wars and the birth rate declined quickly. Since the 1975 Abortion Law was passed the decline in the birth rate has levelled off. There is no causal relationship between birth control legislation and the birth rate. Pronatalists fear a possible collapse of the social security system and the economic consequences of a stagnating birth rate, but the real priority is to adapt the world to the birth rate and not the birth rate to the world. It is still impossible to speak publicly, or advertise, contraception in France, which mitigates the effect of contraception. When those in the developed world consume over three-quarters of the world's wealth women should not be encouraged to have more children. One of the most fundamental of all human rights is the right to decide whether or not to have offspring. Society does not do much to aid the woman who wishes to have children and work. People with large families should receive tax advantages but they should be able to afford to raise their children. The future for the family is in its extension into a tribe and the removal of hierarchal authority.
Informed consent: procedures and forms.
Guidelines for obtaining informed consent from pregnancy termination patients are furnished. In the 1960s, courts began to recognize that physicians had an obligation to adequately inform patients about 1) the nature of their illness; 2) the risks associated with the proposed form of therapy; and 3) the availability of alternative forms of therapy. In recent years, courts have relied less on expert testimony from physicians, and the role of the jury in determining disclosure standards has increased. Physicians must now anticipate the disclosure standards that future juries will impose. A physician can more adequately defend himself in malpractice cases if he has maintained a complete and comprehensive record of all informed consent activities. Consent forms requiring patient acknowledgement of responsibility and providing specific information on the proposed therapy and its risks can attest to the physician's efforts to meet full disclosure standards. Examples of specific consent forms are included.
An analysis of 1150 cases of abortions from the Government R.S.R.M. Lying-in Hospital, Madras.
The Government R.S.R.M. Lying-in Hospital is located in one of the poorest sections of Madras, India, where the abortion rate is very high. The total number of complete abortions during the period, October 1957-November 1958, is 1150; the total number of deliveries including abortions is 10,367, an incidence rate of 11.09%. Of the 1150 cases, 789 (68.61%) were early abortions, up to 12 weeks; 361 (31.39%) were late, from the 13th to 28th week. An analysis of 1000 spontaneous abortions by Simons found that about 75% occurred before the 12th week. 758 abortions were performed on women aged 21-30; 204 occurred among those 31-40. 253 (22%) were primary abortions, i.e. the first pregnancy ended in an abortion and 897 (78%) were secondary abortions, i.e. there were 1 or more viable pregnancies before the abortion. Fetal death may be caused by abnormalities of the ovum, genital tract, or general maternal causes, or rare paternal causes. No cause could be found in 549 (47.74%) cases, but an associated abnormality was found in 601 (52.25%) cases. In 518 cases a single factor caused the abortion; in 83 cases more than a single etiological factor was found. There were 89 habitual aborters (7.74%). 19 of these were primary and 70 were secondary abortions.
Judge strikes down the Hyde Amendment.
Federal Judge John Francis Dooling, Jr., found the Hyde Amendment unconstitutional on January 15, 1980. The decision in McRae vs. Secretary of HEW is being appealed and has no immediate effect. Because of the thoroughness of the arguments on both sides and the fact that the ruling is on constitutional grounds the decision is seen as a possible landmark for federal funding of abortions for indigent women. The most recent Hyde Amendment restricted funds to women whose life is endangered or cases of promptly reported rape. In a 642 page opinion delivered in Brooklyn's Federal District Court, Judge Dooling declared the law invalid not on statutory grounds but on constitutional grounds. The pregnant women's First and Fifth Amendment rights are denied by the Hyde Amendment. Judge Dooling suggested that it is not the right of Congress to write fine definitions of medical necessity. A woman's conscientious decision to terminate her pregnancy is an exercise of the most fundamental rights, allied with her right to be, and surely part of the liberty protected by the First Amendment. The Supreme Court could overturn the McRae decision, but if the Dooling decision stands, the patient and her physician would be the final authority. At the same time Judge Dooling was making his decision, the House of Representatives was moving to restrict abortion funding by amending the statutes that set up Medicaid.
Sudden collapse and death of women obtaining abortions induced with prostaglandin F2a.
2 recent cases of sudden collapse and eventual death of the woman following induction of abortion with prostaglandin F2a (PGF2a) were reported to the Center for Disease Control. These cases are presented in an effort to document this event associated with the use of PGF2a. THese cases represent the 7th and 8th reported abortion deaths associated with PGF2a. The etiology of the sudden collapse is still unknown, but the deaths of these 2 healthy young women undergoing induced abortions with PGF2a should increase clinicians' awareness of some possible risks associated with the use of these new abortifacients. Analysis of these deaths failed to resolve the question of whether instillation of abortifacients should be performed in hospital or nonhospital facilities. These cases represent very rare events associated with the increased use of the prostaglandins as abortifacients.
Abortion: need, services and policies: Virginia.
In a report on Virginia's needs and provisions for abortion services for 1977 published by the Alan Guttmacher Institute, there were a total of 28,180 abortions performed, but there were an estimated 49,390 residents in need of abortion services. Approximately 17% of Virginia residents obtained abortion services outside the state, but 29% were unable to obtain abortion services at all. The largest number of abortions were performed in the Newport News/Norfolk areas, with the second highest number of abortions being performed in Washington, D.C. 70% of the women obtaining abortions were under 25 years old, unmarried, childless, and in their 1st trimester; 57% were whites. Only 18 of Virginia's 98 counties have abortion services with 36% of the providers being metropolitan areas. 69 hospitals in Virginia do not provide abortion services, 42 of which are in counties with no identified abortion services in hospitals, clinics, or doctors' offices. With the high percent of need, these hospitals would have better served their area by providing abortion services.
Abortion deaths in Singapore (1968-1976).
Relevant data on death from abortion that occurred between 1968 and 1976 were collected from the annual reports of the Registrar of Births and Deaths in Singapore in order to analyze abortion deaths. Additional information was obtained from case records of these deaths that occurred in Kandang Kerbau Hospital for Women; this accounted for 57% of the total number of abortion deaths in Singapore. The abortion deaths were grouped into 3 trienniel periods for analysis on trends in relation to 2 major events -- the limited liberalization of abortion legislation in 1970 and the complete liberalization of abortion legislation in 1974. There was a progressive decline in the number of abortion deaths from 15 in the 1st triennium to 9 in the 3rd triennium, a 40% decline, yet abortion continued to be the primary cause of maternal death in Singapore. In 1974-1976 abortion was responsible for 34.6% of all maternal deaths. The number of obstetric deaths declined by 62.5% between the 1st and 3rd triennium. The number of deaths from illegally induced abortions declined from 8 in 1968-1970 period to 1 in 1974-1976, yet there were abortion deaths in each triennium that were not specified as induced or spontaneous. The majority of abortion deaths occurred in the active reproductive age group of 20-39 years. The primary cause of abortion deaths was sepsis. Out of a total of 37 abortion deaths in Singapore, 21 occurred in the Kandang Kerbau Hospital for Women. None of the deaths that occurred in the 3rd triennium was the result of criminal abortion.
Therapeutic abortion in the late second trimester: experience with prostaglandins.
With the realization that abortion could be induced at any gestational stage by prostaglandin therapy, researchers have focused attention on various routes of administration of prostaglandins as well as synthesis of new synthetic prostaglandin analogs. Efficacy rates for the naturally occurring prostaglandins are around 80%, but side effects were often unacceptably severe. Naturally occurring prostaglandins have been administered via the extraovular route and the intraamniotic route. Some recent clinical data are presented which show the great disparity of metabolic activity among individuals receiving naturally occurring prostaglandins for abortion induction as well as the comparative risks of the main methods of midtrimester abortion; the only advantage in using prostaglandins was a shorter induction-abortion interval, for hypertonic saline was significantly safer (P<.05) with the rate of major complications being 1.81/100,000 for saline and 2.9 for prostaglandin F2 alpha. To overcome the clinical liabilities of naturally occurring prostaglandins, a number of synthetic analogs have been developed, most notably the 15-methyl analogs of prostaglandins F2 alpha and E2. The synthetic analogs are reportedly 10-20 times more potent than their natural compounds. The synthetic compounds have been administered by various routes, including intramuscular, vaginal, extraamniotic, and intraamniotic. By the intramuscular route, 94% success has been reported; by the vaginal route, 88.4% reportedly aborted successfully; by the extraamniotic route, 72.6% were reported to successfully abort; and by the intraamniotic route, success was achieved in up to 95.2% of cases. Prostaglandins may also be useful in conjunction with other compounds, including intravenous oxytocin, intraamniotic urea, and insertion of laminaria tents. The combinations are hopefully less likely to induce serious side effects.
Ethacridine-catheter technique for midtrimester abortion.
The impetus for this monograph chapter was the paucity of information in English describing the Rivanol-catheter method of midtrimester abortion. This technique, along with other mechanical techniques, has been used since 1922 in both Japan and Europe. The operative procedure is briefly described, and a study involving 44 attempted inductions is related. Among the 44 catheter-ethacrindine-oxytocin inductions attempted, there was only 1 failure (success rate 97.5%). 27.3% of the patients (n=12) were in gestational weeks 13-15. 29 complete abortions occurred; 14 were incomplete. Average time from induction to abortion was 26 hours, though this varied widely among individuals. In the 13-15 week group, 50% aborted within the 1st 24 hours, and 41.6% within the 2nd 24 hours. The 1 reported failure is 8.4% of the 13-15 week group, but overall the failure rate was 2.5%. Of all patients, regardless of gestational age, 52% aborted within 24 hours, 43% within the 2nd 24 hours, and 2.5% within the 3rd 24 hours. No clinical stigmata of intravascular coagulopathy were reported. Average blood loss in this series was from 200-300 ml. 2 live fetuses were delivered. A table comparing data from another series of patients using the same technique without oxytocin shows a relatively greater number of patients aborting with the oxytocin technique as well as a reduction in the percent failures. In this technique, oxytocin administration is begun 2 hours after instillation of 50 ml of .1% ethacridine.
The ethacridine-catheter method in second-trimester abortion.
Results of a pilot study comparing extraamniotic ethacridine-catheter (E-C) method with the extraamniotic saline method of abortion induction are presented. The study was performed in Sweden. Subjects were eligible for legal abortion and were in the 13th-20th week of pregnancy. The series was made up of 106 cases, 53 induced by saline and 53 by E-C. Alternating patients were administered either 20% saline or a .1% solution of ethacridine extraamniotically through insertion of a rubber cathetic in the uterus. 1 notable difference was the enormously higher incidence of side effects among the saline group; the E-C group, on the other hand, had only 1 case of pain at instillation, 5 cases of fever up to 38, and 2 cases of fever above 38 degrees centigrade. 50 cases of side effects were reported with saline. A larger percentage of successful abortions occurred in the E-C group in both weeks 13-16 and 17-20. Success, defined by a time limit of 72 hours, was 74% in the saline group compared with 94% in the E-C group. Other reported series using E-C show similar statistics, e.g., a 12.5% frequency of complications and 83-100% success rates. The E-C method is advantageous for second trimester abortions because there are no known contraindications, it is inexpensive, it is simple, and it is usually painless. The high success rates within 48-72 hours, the low incidence of side effects, and the relative rarity of serious infections or complications recommend this procedure.
Prevention of Rh sensitization after abortion.
This monograph chapter argues that there can no longer be any doubt that abortion causes a maternal sensitization to Rh or that such sensitization can be prevented with appropriate therapy. To this end, the author recommends a dose of anti-Rho immune globulin of 50 mcg after first trimester pregnancy termination as an international standard. The recommended dose is 300 mcg at term in the U.S., but this varies throughout the world. Therapy should be administered within 72 hours of delivery, though it can be given as late as 28 days after abortion with some evidence of antibody suppression. Topics discussed include: 1) factors affecting maternal sensitization (frequency of fetomaternal transfusion, individual responses to Rh-positive antigen, strength of antigen on fetal erythrocyte, and ABO protection); 2) physiology and detection of fetomaternal transfusion; 3) abortion and rhesus immunization; and 4) anti-Rh prophylaxis after abortion, including discussion of menstrual extraction and second trimester terminations.
Aspirotomy (AT), a combination of suction curettage and evacuation of uterine contents by embryotomy (crushing of uterine contents), was developed by the authors at the Centre for Human Reproduction in Leiden, Holland, to minimize the morbidity associated with various termination procedures for 2nd trimester pregnancy. A study was conducted to demonstrate the safety of early 2nd trimester therapeutic abortion by AT, using local anesthesia without sedation in an outpatient setting. 636 women participated in the study. (Table 25-1 provides details of their characteristics), and 4 specially trained physicians performed the AT. Ergonovine 0.15 mg was administered intramuscularly or intravenously and after local disinfection with Betadine solution, a weighted speculum was introduced into the vagina; 2 ml of a solution of lidocaine 1% with epinephrine 1:200,000 was then injected into the cervix at the 12 o'clock position. 91.2% of the patients were dilated up to 11 mm, with mean cervical dilatation ranging from 9.8 mm at 14 weeks' gestation to 11.6 mm at 17-19 weeks' gestation. Maximal dilatation (15 mm) was achieved in 2 cases at 18 weeks' gestation. Complications at time of operation, during recovery period, and at follow-up the day after the operation were minimal; immediate operative complication rate was 1.7%. 9 patients suffered a blood loss of more than 250 ml; however, no blood transfusions were required. 2 cases of cervical laceration occurred due to a tenaculum tear. Most common complaints reported by 525 women (82.5%) returning for routine examination were postoperative pain (2.4%) and bleeding (2.1%). There was 1 case of excessive hemorrhage (about 300 ml) which did not require further treatment, and 1 case of fever (39C) treated with antibiotics. AT is a safe and practical procedure for terminating 14-19 weeks gestation when high medical standards are observed and when skilled physicians perform the procedure.
Hysterectomy for pregnancy termination and sterilization.
Vaginal or abdominal hysterectomy is the procedure of choice for induced abortion combined with sexual sterilization when associated gynecological diseases are present, and/or when absolute sterility is desired. Between 1970-1977 354 termination of pregnancies through hysterectomy were performed at the Medical University of South Carolina; of these 307 were vaginal, and 47 abdominal. 80% of patients requested the procedure, and 20% selected it after medical advice. Mean age of patients was 31.6, and the predominat indication for abortion was socioeconomic factors. The technique for vaginal hysterectomy, selected when gestational age was less than 15 weeks, was the modified Heaney approach; when associated gynecologic pathology was present, additional surgery was performed concurrently. Operative complications were primarily related to bleeding requiring transfusion, especially with abdominal hysterectomy. Postoperative hospital stay was 4.7 days for vaginal hysterectomy patients, and 5.1 for abdominal hysterectomy patients. Data for both types of hysterectomy reported here favorably with others previously reported. At the same time 22 patients who had become pregnant after previous sterilization chose hysterectomy as a final sterilization measure.
Intraamniotic instillation of saline and prostaglandin for midtrimester abortion.
Based on the author's experience with over 10,000 intraamniotic instillations of prostaglandins (PGs) and saline for midtrimester abortion, a combination PGF2 alpha-saline regimen was found satisfactory for late abortions. In the specific series presented, 502 of 508 patients expelled the fetus vaginally, for a success rate of 98.8%. .8% (n=4) required a 2nd amnioinfusion 24 hours after the 1st infusion of 20% saline (to replace amniocentesed fluid) and 20 mg of PGF2 alpha. 4 patients required hysterectomy, and in 1 patient a dilatation and evacuation was performed. Mean induction-to-abortion interval for the entire series was 16.1 hours. Nullipara abortion-induction interval was 17.4 hours, whereas it was 15 hours for multiparas. 29.6 hours were required for reinjected patients. No live births occurred. Spontaneous placental expulsion occurred in 57% of patients. Digital manipulation was required for another 19%, and curettage was used in 23.6%. Fever was recorded in 3.2% of subjects. Incidence of hemorrhage was 2.4%, and transfusions were necessary 2.2% of the time. Coagulopathy was seen in 6 women (1.2%); nausea severe enough for treatment was encountered in 48% of patients, and vomiting was experienced by 1/3 of the patients. The effectiveneess and undesirable side effects seemed dose-related. This series clearly demonstrates that success rates increase with physician competence and experience with the procedure.
Legal abortion in the world of today.
Current world trends in abortion are analyzed using data from those countries with available statistics. Approximately 9% of the world's population resides in countries where abortion is completely prohibited, 11% in countries where abortion is permitted only to save the life of the mother, 14% in countries where abortions are permissible for broadly defined health reasons, 26% in countries where abortions can be obtained for both social and medical reason, and 40% in countries where abortions are granted upon request. In countries where abortion has recently been legalized, the number of repeat abortions is increasing. In most countries there is a trend toward earlier abortions, but younger women and those who are economically and educationally deprived tend to have abortions at a later gestational age than the rest of the population. Sterilization is frequently performed in combination with pregnancy termination. The complication rate increases for concurrent procedures; however, this risk may be more than compensated for by the avoided pregnancy and childbirth complication risks. Deaths related to childbirth, abortion, and various contraceptive methods are compared using data from the U.S. and Great Britain. The comparisons show that the number of deaths among women of all ages related to the use of any one birth control method, including abortion, is lower than the number of deaths attributed to pregnancy and childbirth among women not using any fertility control method, except for pill users who both smoke and are over 40 years old. The number of deaths is lowest among those women who use barrier methods and abortion in combination to control their fertility. Tables provide abortion data for selected countries in terms of 1) number of abortions; 2) number of abortion/1000 women, aged 15-44; 3) number of abortion/1000 live births; and 4) % distribution of abortions by age, parity, marital status, and gestional age. Another table provides information on deaths related to childbirth, abortion, and contraceptive method for the U.S. and Great Britain.
Discussion summary [of the impacts of legal/illegal abortion].
Two thirds of the world's population have access to legal abortion; a remaining 200 million women of reproductive age do not, a situation which leads to high rates of septic abortion. In the Sudan, where abortion is legal only for medical reasons, most incomplete abortions are induced abortions. Most hospitalized cases were known to have started somewhere else. In Nigeria, where abortion laws are based on the old English system, most abortions are performed illegally on the back streets. The Society of Obstetricians and Gynecologists of Nigeria has recommended that abortion be legalized, but the government is indifferent because of religious and cultural factors and the views of those in authority. Many women obtaining illegal abortions later suffer infertility. In the Philippines there are 10,000/year illegal abortions in Manila. Because of the large Catholic population the chance of legalization is remote. However, in one fertility center, 98% of abortion acceptors are Catholic. The practice of postabortion insertion of IUDs in patients who have not given their consent raised the question of whether or not different standards should be applied in developed and developing countries. The majority of women, when counseled correctly and persuasively in the postabortion situation, will accept and continue to use the IUD.
Biologic obstacles to abortion.
Physiological factors which hinder successful pregnancy termination are outlined in this monograph chapter. Though the vagina's absorptive capacity makes it an ideal instillation route for an abortifacient drug, the genital tract also harbors pathogenic organisms which with minute ascension can invade the adnexa and uterus; these organisms cannot be eradicated simply prior to termination of pregnancy. Injuries to the cervix are another contraindication to abortion. Artifical stretching of the cervix injuries occur when the uterine position is misjudged and excessive force is used in dilatation. In order to convert a pregnant myometrium, progesterone withdrawal is required, but once the placenta becomes the primary progesterone producer (Day 50 of gestation), such withdrawal becomes dangerous. Presently, placental termination is accomplished by instillation of hypertonic solutions and prostaglandins. Injection of hyperosmotic solutions into the uterus results in tissue necrosis, and resident microorganisms will invade altered tissues. The 2nd consequence is activation of the body's coagulation mechanism, leading to clinical defibrination and hemorrhage. Retention of products of conception is another abortion sequelae which results in infection; this complication increases with gestational age. Death rate from anesthesia should also be considered a complication of abortion. In addition, physician misjudgment accounts for some mortalities. Immunological or chemical disruptions of the trophoblast seem the best route for further research in abortion techniques. A direct attack on progesterone production may also yield significant results.
Midtrimester abortion: dilatation and extraction preceded by laminaria.
Of 2887 pregnancy terminations performed from 1973-1977, 5 major complications predominated. The technique used dilatation and extraction preceded by laminaria tent insertion. Subjects were in the gestation range of 14-21 weeks. Abortions were performed on an outpatient basis. Vacuum aspiration and sharp curette were used. Complication 1 was a 20-week post last menstrual period (LMP) abortion on a 19-year-old para 0 who was a severe diabetic with an anencephalic fetus. A hysterotomy was performed because of the fear of retained products causing sepsis, but the uterus was empty and clean. X-rays had been inconclusive because the callvarium had collapsed and fragmented. Complication 2 was a 22-year-old para (18 week LMP) who required a transfusion for estimated blood loss of 1000 ml. Complication 3, a 22-year-old para 0, was 19 weeks from LMP; 10 hours postevacuation she was admitted to another institution because of disseminated intravascular coagulation. Complication 4 occurred in a 22-year-old para 0 who was 17 weeks from LMP. She had 2 previous perforations from other abortion attempts; 10 hours postabortion, the patient admitted herself to another hospital with abdominal pain and a lapatomy was performed. Complication 5 consisted of postoperative chest pain and fever in a 21-year-old para 4. Anaerobic organisms were identified in aspirated pleural fluid and septic pulmonary embolus was diagnosed.
Danfa rural health project evaluation. Ghana.
Evaluation of the Danfa Rural Health Project in Ghana was undertaken to provide a comprehensive review of the project. Focus was on specific project activities, the management, and the relationships of the key parties as well as the overall operation of the project. It was important to evaluate the Danfa Project because it was 1 of the largest long term projects funded by the Agency for International Development (AID) and because of the project's comprehensive nature. The evaluation procedure included identification of project goals, purposes, activities and outcomes as well as measures associated with each of these elements. Each of the activities -- health services/evaluative research, participant training, institutional development, and project management -- were reviewed in detail to use the explicit goals, purposes, outputs and inputs as criteria for project assessment. Summary recommendations based on the evaluation included the following: 1) assignment of additional 1st level nurses based on utilization patterns; 2) consideration of trained village health workers for service at the health center level of the satellite to screen patients and provide 1st-line routine care; 3) requirement that infants return monthly for surveillance for first 6 months or 1 year; 4) more enrolled nurses and villages health workers for the teams at the health center and satellites based on utilization patterns; and 5) development of specialized multidisciplinary programs for the control of diseases prevalent in the program area.
IPPF-ESRAOR panel on the effects of steroidal contraceptives on Asians.
It was recommended in 1977 that an expert group be formed to advise Asian Family Planning Associations on research findings on effects of steroidal contraceptives on Asians and their implications for policy makers, to provide a forum for exchange of research experiences, and to provide close collaboration between scientists and agencies organizing such research. A survey of ongoing projects identified 49 dealing with different aspects of oral and injectable contraceptives. A number of recommendations were made concerning the use of steroidal contraceptives for Asians. The panel reaffirmed the safety of DMPA, which increases milk production and causes less disturbance of metabolism of carbohydrates, lipids, amino acids, vitamins and coagulation function than combined preparations of estrogen and progestagen. The existence of menstrual disturbances due to injection of DMPA was confirmed. The clinical significance of changes associated with use of combined estrogen-progestagen preparations for Asians is not well established, but use of combined preparations causes a decrease of milk volume in lactating women. Combined estrogen-progestagen should be used for short-term spacing and avoided for older women. In CBD programs, women over 35 should be referred to a clinic for a full assessment by a doctor.
Incidence and follow-up of trophoblastic diseases.
The objectives of a follow-up program for mole patients include study of the post-abortal H.C.G. pattern, correlation of the H.C.G. regression pattern with the course of the disease, and facilitation of early diagnosis of residual or malignant trophoblastic disease in mole patients. Follow-up should continue between 6 months and 2 years, with clinical follow-up including history, examination, and investigation for localization of tumor and its metastases, while laboratory follow-up involves H.C.G. estimation. Possible problems of a multicenter follow-up program include wrong diagnosis, incomplete laboratory study, loss to follow-up, and communications difficulties. Potential achievements include the identification of high risk mole patients for chemotherapy, a survival rate greater than 95%, and reduction of cost of health care in a national program.
How to run a family planning clinic.
This handbook covers the following topics: introduction to the Philippine family planning program; starting a family planning clinic (site, equipment and supplies, staff, clinic calendar, procedures for clients, types of contraceptives, initial home visits, and other health services), follow-up (clinic revisits, home visits, effectiveness criteria) and contains flowcharts on family planning motivation, clinic activities, follow-up clinic visits for IUD and oral contraceptive patients.
This examination of the role of birth control in the modern world and the position of the Catholic church was written by a priest especially for Catholics who hesitate to go against the teachings of the Church by practicing birth cntrol. It begins with a discussion of various arguments in favor of birth control starting with Malthus, and considers also the views of Marx, the Protestant theologians, Islamic tradition, Hinduism and Ghandi. A critique is offered on the results and implications of institutionalized family planning programs, which finds that they have failed to fulfill their proclaimed missions of preventing abortions, reducing hunger in the world, and increasing maternal happiness. A statement of the official Catholic position and its rationale is accompanied by a discussion of the values and suppositions behind the Church's position. The role of Catholics in the world is examined from a theological perspective. The work concludes by endorsing the position of the Church and recommending that it be followed.
The Soviet Union and population: theory, problems, and population policy.
Until the important public dialog on 3rd World population issues began in the Soviet Uuion in 1965, ideological limitations and bureaucratic interests prevented policy makers from recognizing the existence of a world of national "population problem." Since then, freer discussions of the Soviet Union's surprising decline in birthrate and labor shortages have led to serious policy questions. Conflicting policy goals, however, have resulted in only modest pronatalist policies. The Soviet population problem is a result of interregional disparities in population growth rates between the highly urbanized Soviet European populations with low birth rates and the least urbanized Central Asians with dramatically higher birth rates. As a result, these essentially Muslim people will provide the only major increases in labor resources and an increasing percentage of Soviet armed forces recruits. Policy planners are thus faced with difficult options. Current policies stressing technological transfers from the west and greater labor productivity, however, are unlikely to solve further labor shortages and regional imbalances. Ultimately, nonEuropana regions will be in an improved bargaining position for more favorable nationwide economic policies and for a greater role in policy planning. (Author's)
Endometrial responses to IUDs [abstract]
Endometrial responses to IUDs can be divided into 4 categories: 1) mechanical modifications, 2) hormonal modifications, 3) vascular modifications, and 4) inflammatory reactions. Mechanical modifications include the shape, resistance, and pliability of IUDs which modify the mucosa morphology. Hormonal modifications occur during the menstrual cycle and are manifest in failures of phase changes; 33E of cases remain in the proliferative stage 9estrogenic phase), 51% remain at the secretory stage, and 16% present an estroprogestative imbalance as either a delay in the glycogen secretion and presistence of mitoses or as a shortened luteal phase with a late secretory aspect. Vascular modifications are the result of extremely distended capillaries with thinned wall. Plasmatic exudation occurs and is accompanied by marked increases in the number of polymorphonuclear leukocytes, lymphocytes, and macrophages. Platelet agglutination is also induced. Inflammatory changes are generally asymptomatic, but when symptoms occur, 75% of cases present with endometritis. The main characteristics include 1) diffuse inflammatory areas situated on the surface and consisting of lymphoplasmocytes and macrogphages; 2) diffuse and focal inflammatory areas throughout the mucosa; 3) layers of polymorphonuclear leukocytes and necrotic cells in the lumen of the glandular cells; and 4) propagation of germs in the fallopian tubes causing salpingitis and pyosalpinx.
Maternal nutrition and lactation performance.
Prolonged breastfeeding has been reported to protect the child from grossly defective weaning foods used in most developing countries. Even grossly malnourished mothers have been known to produced enough milk to keep their children alive. Hytten and Thompson reported that there is no evidence that maternal nutrition affect lactation. This study investigates the lactation performance of an unselected group of nursing mothers from a poor to moderate socioeconomic background, and determines the possible effects of their nutritional state on their breast milk and their infants. 41 urban mothers of a moderate to poor socioeconomic status (aged 18 to 38 years) and with an average of 4 pregnancies resulting in 3 surviving children comprised the study population. The mothers were divided into malnourished M group (n=17) and clinically apparently healthy H group (n=24). Biochemical assessments were made of the mothers and their infants, and an NSIM (Nutritional State Index of the Mother) and NSII (Nutritional State Index of the Infant) were made. The malnourished state of the mothers of group M was confirmed by dietary histories and biochemical assessments. 9 mothers in the H group had 'low' serum albumin values, and only 5 had a urea nitrogen/creatinine nitrogen ratio of above 30. The data suggest that the women were consuming a diet poor in protein but adequate in calories. Both groups of mothers produced milk of suboptimal but nonetheless acceptable composition, those in group M having lower concentration of protein and calories than those in group H. On the average, group H mothers produced a normal amount of milk, while group M mothers produced 22% less milk. Most of the infants were found to be of suboptimal nutritional status like the mothers. There was a high correlation between the NSII and amount of milk and of proximate constituents. NSIM correlated very highly with NSII. Nutrition of pregnant women should be improved to control infant malnutrition.
Organization of clinics -- training -- effective referral systems on outreach.
Although there are 3600 family planning clinics in the Philippines, further development was necessary in order to reach the population of the rural areas. An outreach Project was begun in 1976 which recruits, trains and deploys full-fime outreach workers (FTOWs) at provincial or city, district, and municipal levels and establishes barangay supply points. At the municipal level, each FTOW is responsible for 2000 couples. The FTOWs are information workers, service providers, and community organizers. As of March 1979, 3204 outreach workers had been deployed and 30,670 barangay supply points established. Family planning services are now available from several different types of clinics and providers. The Commission of Population has established a set of Coordination Guidelines for Family Planning and Service Delivery which identify the roles and functions of clinic personnel and fieldworkers in different settings. Ongoing training appropriate to their roles is provided for all categories of personnel. An important function of the community based population field worker to to make referrals for contraceptive services, medical followup and evaluation or for treatment of complications.
Brazilian population problem: a challenge.
Brazil's population problem is characterized by dense urban concentration, with population growth rate of 2.887% and continual migration to the cities. The government has traditionally pursued a pronatalist policy with the object of occupying and developing vacant territories, but the conditions there are found to be unfavorable and the population continues to migrate to urban areas. Family planning services have bee available through the private society, BEMFAM (founded 1965) and the Gynecological Clinic of the Sao Paulo University Medical School. In 1978 certain public officials acknowledged the necessity of fertility control to improve socioeconomic conditions, and there have been other promising signs, but the perspectives on population stabilization in Brazil are described as "a matter of speculation."
Norplant: reversible implant contraception.
Through 2 years of comparative clinical trials, Norplant, a subdermal contraceptive implant system containing the synthetic progestin levonorgestrel, has had a net cumulative pregnancy rate of 0.4 per 100. This rate was significantly below rates for another implant contraceptive and for the TCu 200 IUD. The major side effect of the method has been irregular bleeding. The experience of the pilot clinical study through 3 years and the release rates of levonorgestrel from the implanted capsules indicate that a single administration of Norplant will provide effective protection against pregnancy for at least 5 years. (Author's)
Factors affecting labour force participation rates in Ghana, 1970: case study no. 7.
A study was undertaken to examine the influence of various demographic, educational, and economic factors on the labor force participation rates in Ghana. 1960 and 1970 census data were used for the study. Female participation rates in Ghana were seen to be high relative to many countries, although they are considerably lower than male rates. Female participation rates are only moderately affected by age with peak activity occurring at rather advanced ages. Women in the northern areas and in urban areas have lower participation rates. In fact, due to the inhibiting effect of school attendance, participation rates for both sexes were lower in urban areas. Participation rates were positively associated with migration rates for males and negatively associated for females. Childcare was found not to be incompatible with female economic activity. Female rates increased between 1960 and 1970.
Female participation in economic activity in Colombia: case study no. 1.
Fertility and labor force participation in Colombia were investigated. It was hypothesized that fertility differences are related to differences in the division of labor between family work and labor activities outside the home. The fertility of analysis was based on the National Fertility Survey conducted by the National Association of Medical Schools in 1970. A stratified sample of 3000 women was obtained, ranging in age from 15-50 years. The analysis of female employment was based on the Fifth Statistics in 1971, a survey using a probability sample stratified by region. A sub-sample of 4312 women, 12 years of age and older, for whom information on occupational position has been coded was used. Using multiple regression analysis, it was found that women who were unpaid family workers had higher fertility, while women who worked for pay outside the home have lower fertility. In the case of female employment, it was found that as explanatory variables, the relationship to the household head, marital status and occupational status performed the best of all. For the fertility study, age, duration of marriage and the educational level were found to have the best predictive power.
Treatment of small bowel diarrhea with electrolyte glucose drink.
The results of 102 cases treated with an oral electrolyte-glucose solution for rehydration caused by mild cases of small bowel diarrhea without using an antimicrobial agent in conjunction are presented. Clinical features, such as frequency of loose bowel movement, age distributions, and other relevant symptomatology are provided tabularly. The solution used consisted of: sodium chloride, .85 gm; potassium bicarbonate, 1 gm.; glucose, 17.5 gm.; boiled and cooled water, 500 ml. 97 of 102 were treated only with the oral electrolyte-glucose solution, and the remainder received intravenous fluid before initiation of oral rehydration. Due to follow-up problems, 13 cases were omitted from the statistical analysis; of the remaining 89, 84 were controlled within 72 hours (as judged by cessation of loose bowel movements). During therapy, breastfeeding or cow's milk was expressly forbidden, but 4 of the 5 failures were later discovered to have recieved breastfeedings, and 1 was marasmic. The treatment of small diarrhea, not having persistent vomiting or shock, with some suitable oral electrolyte-glucose solution only is highly successful, safe, and inexpensive. Success rate was 94.38%.
El Salvador contraceptive prevalence survey-1978 [tables]
The contraceptive prevalence survey is based on responses by 2,962 people, 932 metro (San Salvador), 903 other urban, and 1127 rural. 23.1% of women queried were in the 15-19 age group, 19.9% 20-24, 12.6% 25-29, 14.4% 30-34 (1978). In the same year, 28.7% were married, 31% were in consensual unions, 24.6% were single, and 15.7% were separated, widowed or divorced. The mean number of children for the age 25-29 group was 2.05 in the metro area, 2.80 in the urban area, and 3.49 rural. The total averages for the 30-44, 35-39, and 40-44 age groups were 4.5, 5.6, and 6.12 children, respectively. Estimates of the general fertility rate (GFR), total fertility rate (TFR), and Crude Birth Rate by Residence (CBR) are 208, 6.3, and 43, respectively. In the rural area the rates are 272, 8.4, and 51, respectively. The percentages of women 15-44 using contraception in 1978 were all women, 22.3%; ever married women, 29.1%; current married women, 34.4%; and exposed currently married women, 42.8%. The type of contraception used by currently married women is 18% sterilization, 8.7% orals, 3.3% IUD, 1.7% Rhythm, 1.5% condom, and 1.2% other. Of the 65.6% currently married women not using any contraception, 43.6% are metro, 58.1% urban, and 73.8% rural. Of the currently using women 27% have 3 years of primary school, 45.7% 4-6 years primary school, and 52.6% secondary school.
Gram-negative septicemia is an increasing medical problem. Mortality rate is high, and treatment can prove disappointing. The problem is compounded with the emergence of resistant gram-negative rods; infection, even in patients undergoing antibiotic therapy, may be brought about by relatively "nonpathogenic" bacteria (e.g., E. coli, P. vulgaris, A. aerogenes). Hypotension is a common complication and is attributed to the pooling of large quantities of blood in the vascular tree. A disseminated microscopic thrombosis with multiple fibrin deposits in the liver, lungs, renal glomeruli and spleen is often observed, as is hemorrhagic necrosis of the bowel wall. Other pathologic changes include a rise in hematocrit and red-cell mass with a decrease in plasma volume and a drop in plasma fibrinogen, and poor perfusion of the coronary arteries and myocardium. In addition, the heart can become dilated, atonic and flabby. A further decrease in cardiac output could result in subsequent renal failure, shock, and death. Prompt recognition of endotoxin shock, plus vigorous therapy, including early evacuation of the uterus, or hysterectomy in unresponsive patients, may increase survival rates of patients. Although the clinical picture of endotoxin shock is variable, a general pattern can be discerned: in the early phase, a temperature of 101-105 degrees, tachycardia (110-180/minutes), flushing of skin, profuse diaphoresis, and anxiety are observed. In the late phase, subnormal temperature, marked pallor and sometimes ecchymosis, drop in systolic blood pressure, oliguria, pulmonary edema, and death, are observed. 10 cases of endotoxic shock are reviewed.
Completeness and accuracy of reporting induced abortions performed in Hawaii's hospitals, 1970-74.
The article follows up on documented cases of abortions performed in Hawaiian hospitals for the years 1970-1974 in order to examine and evaluate the completeness and accuracy of reporting induced abortions to the official State agency. The study pursues record linkage as a valuable and economic process for checking completeness of data and accuracy of data regarding the study of separate vital events on the same persons. Two sets of records were initially linked by computer on the criteria of first name, maiden name, date of the abortion, age, and ethnic background of the subjects. The scan produced a total of 18,531 induced abortions ascertained in hospitals for the period specified with further data regarding official causes of fetal death and live birth records listed as filed in the State health department. The survey indicated that 96.1 percent of the hospital abortions were matched in official certificates. Of a total 17,550 abortions classified as elective, 98.7 percent were recorded as such in the certificate file. Remaining cases were reported as either therapeutic or "unknown" for cause of fetal death. When the study considered the probability of matches for those abortions without complete linking information and possible errors in the information source, the estimates of underreporting to the State health department were a maximum of 3.9 percent and a minimum of 1.2 percent. The mean value found for underreporting was 2.6 percent. The paper supports the validity of such linkage studies, since the underreporting of induced abortions is becoming serious with the widespread practice of abortions in nonhospital institutions within recent years. (Author's modified)
[Clinical aspects of medroxyprogesterone injection as a contraceptive method]
This study analyzes effectiveness, acceptance and side effects of treatment with medroxyprogesterone acetate on 25 patients for 324 months, a total of 27 woman-years. 60% of patients continued the treatment, 16% did not return for follow-up, 2 patients abandoned treatment for medical reasons; 70.8% of patients slightly gained weight. Menstruation disorders were frequent, especially metrorrhagia and amenorrhea. Libido was unchanged in 76% of patients, but decreased in 20%. There were no side effects on lactation, but cases of varicose veins worsened considerably. (Summary in ENG)
[Psychiatric aspects of therapeutic-abortion (Letter)]
Although careful evaluation is undertaken to determine whether a psychological reason for abortion exists, a more fundamental aspect remains to be considered. As the fetus itself is a human being from the point of conception, abortion raises the question if one life is worth more than another. Both the mother's life and the fetus's life should be considered equally.
2 prostaglandin (PG) compounds, PGF2 alpha and PGE2, were used to induce abortion in 24 women. 6 women with hydatidiform moles underwent i.v. or extra-ovular PG treatment, with an average induction-abortion interval (i.a.i.) of 8.5 hours. 3 women, 21-30 weeks pregnant, underwent abortion because of fetal anencephaly. They were given 1-3 doses of PGs intraamnially, supplemented with a few hours of i.v. ocytocin treatment, with an average i.a.i. of 49 hours and 53 minutes. 10 cases of missed abortion were treated mainly by intraamnial PG instillation, with an average i.a.i. of 18.5 hours. 5 cases of intrauterine death were treated with i.v. administration of PGs with an average i.a.i. of 12 hours and 42 minutes. Vomiting, nausea, and diarrhea were the most commonly reported side effects. No cervical injuries were reported. (Summary in ENG)
In most Arab societies today, the entire burden of family planning and contraception rests on the woman. The position maintained by Arab countries on the question of birth control varies according to population size and growth rates and their relationship to production and to the economy and material resources of the country. And as there is nothing in the Koran that supports or opposes birth control or contraception, the significant factor in practicing or not practicing family planning is not religion but the economy. Concerning abortion, the only alternative if birth control methods fail, it is, like most other matters related to women and sex in Arab society, still an issue fraught with contradiction, another reflection of the double moral standards inherent in a patriarchal class society. In Egypt, estimates indicate that out of every 4 pregnancies, 1 ends in illegal abortion, and the majority of abortions involve married mothers between 25 and 35. Of these, 80% are mothers with 2 or more children but feel that their families cannot bear the economic and social consequences of an additional child. The legalization of abortion in Egypt or other Arab countries would not have a noticable effect on the frequency of operations, but it would have the advantage of bringing out in the open what is at present an obscure and often criminal procedure. It would also afford poorer women the possibility of receiving services available to their wealthier counterparts, and would definitely lead to improvement of services, avoidance of negligence, and a reduction in complications.
[Permanent control of female fertility by surgical methods]
The results of 1393 cases of female sterilization are presented in the article. Several techniques of tubal ligation were employed, postpartum and postabortum minilaparotomy, Pomeroy method, and fimbriectomy. Operative procedures are given in details for every technique. Main reason for sterilization was permanent contraception; 92% of patients belonged to low socioeconomic classes, were about 34 years old, with parity over 5, and most with antecedents of abortion and of cesarean section. There were no complications; late morbidity was only 1.47%, and mainly caused by transvaginal surgery. Minilaparotomy was found to give better results than conventional laparotomy; average time for the procedure was 10'. Hospital stay was 3.2 days, and paracervical block was used in over 92% of cases. (Summary in ENG)
FAmily planning methods are not well known in Mozambique, and abortion is too often used as a contraceptive measure. Not only women in fertile age, but very often paramedical personnel are not well acquainted with modern techniques, and/or are too much imbued with a mentality and attitude which is traditionally against birth control. It is sometimes the same personnel who cannot give advice about the spacing of children, is the one who performs the abortion. In 1976 in the Central Hospital of Moputo 2204 curettages were perfo4med following abortions induced at home. The cost to the hospital per women is much higher than that of an IUD insertion; the IUD is the best accepted contraceptive method among women practicing contraception. Abortions are often induced by means of traditional methods and during the weekends, to unable women to go to work the following Monday. Many pharmacies will not sell contraceptives without a prescription; it is, however, often difficult to obtain such a prescription. The problem of sex education in Mozambique is as serious as the problem of illiteracy.
New combined oral contraceptive with incremental progestogen dosage regimen.
In a study of 506 women, 272 took a total of 2124 cycles of combined preparations of norgestrel and 234 women took a total of 2002 cycles of a combined contraceptive with incremental progestogen doses, in which the total D-norgestrel was 1800 g as opposed to 5250 g in the combined preparation. The step-up preparation group had a similar rate of side effects as the combined preparation group; however, women using the step-up preparation had significantly diminished intermenstrual bleeding after the 6th month of use. The step-up regimen has not induced any cases of endometrial hyperplasia but does have an inhibiting effect on endometrial proliferation in the 1st half of the cycle. The step-up preparation has similar effects on the hypothalamo-hypophysial-ovarian axis as the combined pill. The step-up preparation appears to inhibit ovulation from the 1st cycle as indicated by the absence of LH and FSH midcycle peaks and the low 17 beta-estradiol levels in the 2nd half of the cycle; therefore, the step-up preparation should be classified as a new combined, not sequential, oral contraceptive.
In 1618 the population of Austria was 1,500,000, the average annual growth rate, 2.6; in 1975 the population was about 7,519,900, the average annual growth rate, 2.1. The total fertility rate was 4.1 in 1900, 2.2 in 1955, 2.8 in 1964, 2.7 in 1966, 2.5 in 1969, and 1.8 in 1975. Post-war losses of men (1951: 866 males to 1000 females), were stabilized by 1971 when the ratio was 1,013 males to 1000 females. Between 1951-63 the number of first birt increased by 21%, of second births by 39%, of third births by 65%, of fourth and fifth births by 67%. BEtween 1963-75 the corresponding decreases amounted to 21%, 23%, 43%, and 56%. Fertility rates are notably higher in rural areas than urban. In 1971 the rural fertility rate was 72.9/1000; the urban rate was 55.3/1000. The rapid industrialization in the 20th century has resulted in a decline of agricultural employment from 42.6% in 1923 to 14.7% in 1971 of the total labor force. In 1971 the average parity of married women aged 35-55 was farmers wives, 3.5, blue collar workers, 2.5, and nonagricultural self-employed or employers, 2.1, and white collar workers, 1.8 live births. From 1871-5 the death rate was about 31/1000. In the following 30 years the death rate decreased by 29% to 21.9. From 1951-5 the death rate was 12.2/1000. Since then the death rate has increased to an average of 12.3 in 1971. The infant death rate dropped by 44% (male) and 43% (female) between 1950-2 and 1960-2, a pace which slackened in the following 10 years.
Statistical yearbook of the Republic of China: 1976.
In the People's Republic of China in 1960 there were 35,497 female students enrolled in pre-primary school of a total 79,702. At the first level there were 880,735 female students of a total 1,879,428. At the second level in teacher training there are 3,336 females enrolled, compared to a total 7,522. At the third level there were 8,204 females, compared to a total 35,060. In 1970 a total of 3,969,150 people were enrolled as students; 1,813,028 were female. At the pre-primary level 41,017 were female students, of a total 91,440. At the first level there were l,l74,935 females enrolled, compared to a total 2,428,585. 384 females were enrolled at the second level in teacher training, compared to 924 total. At the third level, 73,323 women were enrolled, compared to a total of 203,473. In 1975 4,424,778 people were enrolled in institutions; 2,063,703 were female. 117,262 people were enrolled at the pre-primary level; 54,642 were female. At the first level 2,349,603 people were enrolled; 1,141,746 were female. At the second level 1,497,848 were enrolled; 642,717 were female. 2,848 were enrolled in teacher training; 1,160 were female. 289,435 people were enrolled at the third level, 106,381 were female. There were 4,484 institutions extant in 1975.
Migration policy for whom? A case study of the political context of migration in Sweden.
In the attempt to provide more comprehensive information on rural-urban migration in Sweden, in-depth interviews were conducted with 96 people who had moved from a northern coastal village to Stockholm, mostly between 1962 and 1972. Motivations, attitudes and feelings about the experiences of the migrants were highly accessible through the open-ended form. The distribution of reasons for moving to Stockholm was essentially the same for the total sample as for the subset who returned to Osthammer. The shift in reasons for returning is clear: work incentive declines markedly, from 33% to 6%, in favor of family, social, and physical environment. On arrival in Stockholm, 78% of the migrants obtained work. The remainder were students, housewives, or retired people for the most part. Only 2% were unable to find work desired. Although 52% reported improved income in Stockholm and at least 34% benefited from further education, 1/3 of the migrants opted for a return to village life. The life cycle of returnees differed markedly from that at the time of migration to Stockholm. Major changes included marriage, divorce, and more children. The move to Stockholm brought real economic gains that were reflected in job status, income, and, less directly, in education acquired. These were clearly offset by a higher cost of living and by social and psychological stresses due to disrupted lifestyles. The concept of economic priority in migration was supported, but noneconomic factors which receive little attention in research and policy-making proved important.
Report of the Advisory Committee on Migration and Urbanization on its first session.
At the 1st session of the Advisory Committee on Migration and Urbanization of the Economic and Social Commission for Asia and the Pacific (ESCAP), representatives of Sri Lanka, the Republic of Korea, the Philippines and Indonesia presented major findings regarding migration, urbanization and the levels of urban and rural development. The analyses of migration were based on the new tabulations designed by ESCAP and generated from the 1970 round of censuses. These showed the destinations of migration classified by settlement size and migrant/non-migrant socioeconomic differentials. Certain characteristi were common to the migration patterns of the 4 countries. The fact that it was mostly young people who moved was noted by all the representatives. The sex differential varied from country to country: in Indonesia and Sri Lanka, males tended to move more than females; the situation was reversed in the Philippines and the Republic of Korea. An important characteristic of migrants in all the countries was that they tended to have lower rates of unemployment than non-migrants. The relationship between migration and fertility was difficult to establish from the data. There appeared to be some evidence to suggest that migrant women tended to have fewer children than non-migrant women, but the evidence was unclear. The survey documents were presented for discussion. They consisted of the core questionnaire and the draft supporting manuals on interviewers' instructions, interviewer trainers' instructions, supervisors' instructions, office editing, coding and transcriptio tabulation plan and survey organization and monitoring.
Urbanization and the growth of small towns in Sri Lanka, 1901-71.
Using published census data, this paper examines the pattern of urbanization in Sri Lanka from 1901 to 1971. Like most South Asian countries, Sri Lanka shows a low level of urbanization. The annual growth rate for the 70 year period has been well under 3%, while the national population has grown by less than 2% per annum. Contrary to the widely held belief that medium sized towns have dominated urbanization in Sri Lanka, this paper demonstrates that the highest growth rates have occurred in the small towns during most of the century and that this phenomenon has created a pattern of decentralized urbanization. In addition, mitigated primacy and metropolitanization have characterized the growth of the capital city of Colombo during the recent past. The paper reviews several factors affecting growth (amid ruralward migration) and creating an incipient pattern of decentralized urbanization. Urbanization is postulated as a response to the demands of the political economy of the country. (Author's)
Complications of surgical evacuation procedures for abortions after 12 weeks' gestation.
This monograph chapter presents trends in the number of dilatation and evacuation (D and E) procedures performed in the United States over recent years, demonstrates that the 13-15 week interval is the most important gestational age for D and E, and summarizes available data on complications and deaths associated with this procedure. In the U.S., the percentage of D and E procedures has been steadily increasing; by 1976, D and E accounted for 75% of all abortion procedures in the 13-15 week gestational group. In general, complications associated with D and E are similar to those with any curettage technique, but are more frequent and more severe. The most common complications are infection and hemorrhage: rate of pelvic infection in the U.S. ranges from 0-3.8/100 abortions, and rate of reported hemorrhage ranges from 0-3.8 also. Cervical injury from D and E is approximately as common as pelvic infection. Damage to internal os during dilatation is a major complication with D and E. Disseminated intravascular coagulation has also been associated, though rarely, with D and E. Mortality from D and E results from 2 predominate syndromes: hypovolemic shock after hemorrhage caused by uterine perforation and infection secondary to incomplete evacuation. From 1972-1976, the Center for Disease Control reported 14 D and E abortion associated deaths. Risk of death from D and E increases as gestation age increases; death-to-case rate was 7.6/100,000 abortions for D and Es performed at 13-15 weeks, 13.2 for 16-20 weeks, and 43.1 for greater than 21 weeks. Though higher than other curettage procedures, the overall risk of death from D and E is lower than the risk from instillation procedures except beyond 20 weeks of gestation.
Research in the use of prostaglandin analogues.
This monograph chapter summarizes a physician's experience using prostaglandins, in the form of a long-acting vaginal suppository, for early midtrimester abortion induction and for cervical dilatation to allow simple evacuation of the uterus. 50 women, all admitted in gestational week 13-15, volunteered for this study; 27 were nulliparous. Treatment included 1 vaginal suppository containing 3 or 3.5 mg of 15-methyl prostaglandin F 2 alpha methyl ester (PGF2A) in 2.2 gm of Witepsol E-76 (base). Of the 50 patients, 46 (92%) aborted successfully within 24 hours, and the remaining 4 patients received an additional intramuscular injection of PGF2A; all patients aborted within 36 hours. Mean abortion-induction interval was 14.3 hours, and incidence of complete abortion was 40%. Bleeding was estimated as less than 250 ml in 84% of patients. Also reported are results of a study of the usefulness of prostaglandin therapy for cervical dilatation preoperatively in patients 12-14 weeks pregnant. 40 patients of 12-14 week gestational ages were treated with 1 vaginal suppository containing either 1 or 2.5 mg of PGF2A; treatment was followed by vacuum aspiration 12 hours later. Mean cervical dilatation was 10.3 mm with the 1-mg dose and 12.5 mm with the 2.5-mg dosage. Bleeding, including the conceptus, was less than 100 ml in more than 84% of subjects. 25% needed additional mechanical dilatation of 4 mm. The noninvasive nature of single suppository treatment for second trimester abortion will probably reduce operative complications.
Extraamniotic prostaglandin E2 in gel for induced abortion.
This monograph chapter relates a study evaluating a single extraamniotic dose (injection) of prostaglandin E2 (PGE2) in a viscous gel for efficacy in cervical dilatation preoperatively in first trimester patients and in pregnancy termination of second trimester patients in whom mechanical dilatation may be harmful. 35 first trimester and 52 second trimester (total, 87) patients were studied. For first trimester patients, 2 dose schedules were used: 2.5-3 mg of PGE2 or 3.5-4 mg of PGE2, injected through a catheter in a 10-ml dose of gel. Cervical evacuation took place 6-24 hours post-injection. For midtrimester subjects, the initial dose was 1.5-2 mg, which was later increased to 2.5-3 and 3.5-4 mg, administered extraamniotically. Among the first trimester subjects, 17 received the 2.5-3 mg dose; mean cervical dilatation was 10.76 mm and mean time to abortion was 10.25 hours. 18 patients in first trimester received the 3.5-4 mg dose; mean dilatation was 11.6 mm and mean time to abortion was 8.54 hours. The change in cervical dilatation before and after PGE2 administration was statistically significant in both groups (P<.001). No serious side effects were encountered; with uterine cramps, vomiting, and diarrhea predominating. For midtrimester patients, after a single dose of PGE2 there was little increase in the rate of successful abortion among the 3 dosage regimens. When the initial doses were increased to a maximum of 3.5-4 mg, mean time to successful abortion decreased from 12.20 hours to 7.45 hours with a single dose. Because duration of the gel's activity was limited, repeated doses were administered if abortion was not completed with 1 dose; mean time to abortion was 14 hours and 17 minutes using the highest dose schedule given as a single or repeated injection; this is comparable to other extraamniotic prostaglandin techniques. Side effects were greatest among the highest dosage groups. 13% of midtrimester patients had pyrexia of 38 degrees centigrade. Vomiting occurred in 44%. 2 patients experienced diarrhea, and 2 patients required transfusion for hemorrhage after curettage. PGE2 suspended at a relatively high dose in a slow-release gel induced abortion in patients from 6-26 weeks of gestation.
Reducing the morbidity of vacuum aspiration abortion.
The technique of vacuum aspiration abortion is reviewed with a view to making improvements. The skill of the operator is crucial to the success of the procedure. This includes the empathy and gentleness of the practitioner. Complication data indicate that training programs for the performance and management of 1st trimester abortions would lower these rates. Proper equipment is necessary to safe performance of vacuum aspiration. A study was done of 7272 procedures performed at Preterm during 1976. Complications that occurred during this period are tabulated and categorized. Performance of abortions before the 12 week of gestation is the most important factor in reducing complications. It is necessary to have a positive pregnancy test and concurrent pelvic findings before abortion procedures are carried out. Various preabortion, intraabortion, and postabortion complications are discussed. Ultrasonography should be used if there is doubt as to the gestational age. When only a small amount of tissue is obtained, careful examination should be conducted to determine the reason. Early reevacuation may be necessary to avoid incomplete abortion. A routine follow-up examination is useful in diagnosing a failed procedure, i.e., a continuing pregnancy.
Biophysical detection of early pregnancy.
Sonography, or diagnostic ultrasound, has many established uses involving the biophysical evaluation of a pregnant uterus. The normal intrauterine pregnancy can be ultrasonically visualized by 5 weeks from the 1st day of the last menstrual period. By 7-8 weeks gestation the heart valvular motion can be recorded by time-motion. The fetal crown-rump length (CRL), detectable by sonography, can be used to predict gestational age with an accuracy of 4.7 days in 95% of the population. Sonographic visualizations of uterine pregnancies are included. The fetal biparietal diameter (BPD), also detectable by sonography, may be localized and measured by 14 weeks gestation; this measurement also correlates with length of pregnancy. Ultrasound is a useful diagnostic tool for abnormal conditions connected with 1st-trimester pregnancy terminations, including inadequate pelvic examination, pelvic tumor, and ectopic and multiple pregnancies. Diagnostic ultrasound is routinely used in combination with amniocentesis which may result in 2nd-trimester abortions only where there is a discrepancy between menstrual dates and fundal length of the fetus and in the case of complications arising during the course of pregnancy termination. 2 cases of complications where ultrasound proved useful are cited. 1 involved an ovarian cyst and the other involved the absence of cervical dilation following saline injection.
In 1975 legal abortion in Sweden was made freely available up to and including the 18th week of pregnancy with all fees paid by the government. The increase in the number of abortions performed following passage of this law was moderate, only 5% during the 1st year. Currently there are 30,000 legal abortions yearly and nearly 100,000 births. The yearly abortion rate now seems to have stabilized. Counseling facilities and contraceptive supply clinics have been made more available, especially to young people. Since there is a high percentage of repeat aborters, the need for contraceptive counseling is recognized. Most abortions in Sweden, as a result of this new law, now take place during the 1st trimester of pregnancy. Vacuum aspiration, with or without dilatation, is the most prevalent technique. Second trimester abortions utilize saline, prostaglandins, or ethacridine, with saline the method of choice for abortions after the 20th week of pregnancy.
Menstrual regulation: medical techniques.
Studies show that abortion can be induced using intravenous or intravaginal administration of naturally occurring prostaglandin PGE2 or PGF2 during early pregnancy. However, effective doses have been related to the high frequency of side effects. Mocsary and Csapo reported that intrauterine administration of 5 mg PGF2a into 428 pregnant women (mean menstrual delay, 13 days) was effective in 95.3% of the cases. Others reported equally effective results with PGE2 and PGF2a. Prostaglandin analogues have also proved successful in inducing abortion by the intravenous route. Vaginal administration of prostaglandin analogues appears to be more promising for pregnancy termination than does the parent compounds PGE2 and PGF2a. A comparison of the prostaglandin treatment with vacuum aspiration procedures shows that both methods are equally effective in terminating early pregnancies. Both are suitable as outpatient procedures. The advantages of vacuum aspiration are less hospitalization stay, fewer gastrointestinal side effects, and shorter period of bleeding. These advantages are outweighed however by the benefits of the prostaglandin treatment, namely, simplicity of vaginal administration; its potential for self-administration; and the anonimity of the medical treatment.
Discussion summary [of informed consent and patient counseling] .
The counseling process enables staff members to interact intelligently and sensitively with the patient, who in turn makes choices in consonance with her feelings brought out during the counseling. Counseling therefore, along with informed consent procedures, is important in the delivery of pregnancy termination services. A vioeotape cassette explaining the risks and benefits of a certain procedure and a printed transcript of the videotape have proven effective in assuring effective informed consent from the patient. The patient reads the transcript before signing the consent form, and also retains copies of all the material. In counseling, it is important that the patient be made aware of the risk associated with continuation of pregnancy. Statistics show that pregnancy and childbirth have higher mortality rates than does abortion. This information should be provided to the patient as it generally helps to support the patient's decision to abort her pregnancy. Another concern is the physician's legal responsibility in recommending a controversial procedure (e.g., outpatient dilatation and evacuation (D and E)). In some states, the law requires that further explanation of the D and E procedure be done, in case a lawyer argues about the experimental nature of D and E. Another legal issue currently under debate is the protection of nurses and other paramedical personnel who perform abortion under the supervision of physicians. Other problems associated with informed consent and counseling procedures include possibility of malpractice suit with the use of an elaborate type of consent form, and special counseling needs of certain women (those who are distressed about their abortion decision) and teenagers. Regional training programs for abortion counseling should be established.
Alternatives for cervical dilatation: work in progress.
The biology of cervical dilatation during pregnancy is not well known. Forcible dilatation of the cervix to induce abortion has been known to result in tearing of the internal cervical os. Although modern studies have found little evidence regarding the adverse effects of induced abortion on subsequent pregnancies, a large WHO multicenter trial revealed an increase in sequelae among women who had dilatation and curettage (D and C) abortion, but not among those who had dilatation and vacuum extraction. English studies also reported an increased incidence of midtrimester pregnancy loss in women with previous abortion, especially when the procedure used had resulted in cervical laceration. Cervical dilatation, which has been in practice since antiquity, is achieved through the use of various methods such as laminaria tent; Anker dilator; balloon dilators; vibrating dilators; and prostaglandins and its analogues. The physical characteristics of the pregnant cervix contributes to the difficulty of developing new dilators. Currently, an expanding dilator with all the benefits of the laminaria tent and none of the bad is being developed. Analysis of the relationship between size of laminaria tents and amount of dilatation achieved (Table 16-2) shows that in general, larger laminaria results in greater cervical dilatation, and increasing the numbers of laminaria also increases the dilatation achieved. It is hoped that current research on cervical dilatation will give rise to totally safe and atraumatic means of dilatation of the cervix.
Discussion summary [of first-trimester pregnancy termination].
This paper describes various pregnancy termination procedures and their physical and psychological sequelae on subsequent pregnancies. The desirability of the soft curettage equipment was mentioned in the light of the availability fo the silent type of pump currently used for uterine evacuation in countries with adequate electricity and technology. In addition, hand syringes are as effective as electrical pumps, produce less sound and are simpler to manufacture and use. Soft dilatation is also achieved in a few minutes to enable termination of pregnancy, eliminating the need for patient to return in 24 hours as required with laminaria use. Problems with laminaria use include possibility of breakage during removal (ways of handling this situation are described); increased risk of infection; and risk of cervical damage. Other issues briefly addressed are the possibility of litigation resulting from postabortal complications, and the amount of blood loss which constitutes hemmorrhage. With regard to low birthweight in subsequent pregnancies, degree of cervical dilatation is important in comparing abortion methods (e.g., dilatation and curettage and vacuum aspiration (VA)), as is the technique used in achieving dilatation. Time of termination procedure and events at subsequent delivery should also be considered. As regards the effect of multiple pregnancy terminations on subsequent pregnancies, the Eastern European studies suggest that the frequency of employing termination procedures is safe only to a certain limit. The skill of the operator is a significant factor in considering the complication rate of termination procedures. The WHO studies suggest that there is a 4-fold difference in complication rate between the worst operator and the best operator. Other issues discussed included the optional time to perform early abortion; psychological or psychiatric problems associated with abortion; failure rates of tubal occlusion methods performed in conjunction with abortion; and menstrual regulation procedures being performed under adverse conditions in developing countries.
Abortion (amendment) bill. [Letter]
On Feb. 8, the Abortion (Amendment) Bill comes back to the floor of the House of Commons. Although it has undergone extensive changes during the committee stage, the Bill still contains provisions which I think are disturbing, and I would urge doctors to give their members of Parliament their views on the Bill. The 4 main provisions are: 1) the lowering of the time limit to twenty weeks; 2) a change in the basis for abortion so that it would only be available when there was substantial risk to the mother or to the rest of the family if the pregnancy continued; 3) extension of the conscience clause such that no reason would be necessary to withdraw from assisting with an abortion; 4) a change in the basis under which the charities involved in abortion counseling would operate. The 1967 Act has proven to be a workable piece of legislation: the proposed changes represent an attack not only on the position of women in this country but also on the medical profession. (Author's)
Amenorrhea and infertility associated with oral contraception.
This study presents data on a series of 48 patients presenting in a clinic with postpill amenorrhea and infertility exceeding 1 year's duration. Presented tabularly are the full histories and laboratory work-ups of these women; however, no common etiological role is obvious. 29 of the 48 were treated to completion with various ovulation stimulating regimens: periods returned in 24 patients, and 10 pregnancies were successfully begun. Therapies included operations for pituitary tumor, cyclic hormone withdrawal bleeding for primary ovarian failure (n=2), 1 case of untreatable Cushing's syndrome, and diagnosis of other causes of infertility (for example, husband related, n=8). In the remaining 36 treated, Clomid and human pituitary gonadotropin therapies were initiated; all of these patients were determined to suffer from uncomplicated postpill amenorrhea with no other underlying diseases. Clomid was administered in 100-mg doses 4 times on the 3rd day of withdrawal bleeding and human pituitary gonadotropin was administered post-Clomid failure.
Since the liberalization in 1970 of the abortion laws in the U.S., the anti-abortionists have succeeded in gradually reimposing restrictions on abortion. First they developed strategies aimed at obstructing attempts to equalize abortion accessibility. They accomplished this by promoting the passage of state laws requiring parental consent and tightening the time limits on abortion. They also used harassment tactics, such as rezoning areas in which abortion clinics were planned. Next they fought to impose economic constraints. These efforts meet with success in 1976 when the Hyde Amendment, banning the use of Medicaid funds for the termination of non-life threatening pregnancies, was passed, and in 1977 when the Supreme Court declared that states could legally withdraw abortion financing. In the past 4/5 of the funds used to pay for abortions for indigent women came from the federal government, and now many states are also expected to withdraw funding. The anti-abortionists have been able to garner public support largely because of the general trend toward retrenchment in the U.S. The ultimate aim of the anti-abortion forces is to deny all women the right to have an abortion.
Abortion was frequently practiced in North America during the period from 1600 to 1900. Many tribal societies knew how to induce abortions. They used a variety of methods including the use of black root and cedar root as abortifacient agents. During the colonial period, the legality of abortion varied from colony to colony and reflected the attitude of the European country which controlled the specific colony. In the British colonies abortions were legal if they were performed prior to quickening. In the French colonies abortions were frequently performed despite the fact that they were considered to be illegal. In the Spanish and Portuguese colonies abortion was illegal. From 1776 until the mid-1800s abortion was viewed as socially unacceptable; however, abortions were not illegal in most states. During the 1860s a number of states passed anti-abortion laws. Most of these laws were ambiguous and difficult to enforce. After 1860 stronger anti-abortion laws were passed and these laws were more vigorously enforced. As a result, many women began to utilize illegal underground abortion services. Although abortion was legalized in 1970, many women are still forced to obtain illegal abortion or to perform self-abortions due to the economic constraints imposed by the Hyde Amendment and the unavailability of services in many areas. Throughout the colonial period and during the early years of the republic, the abortion situation for slave women was different than for other women. Slaves were subject to the rules of their owners, and the owners refused to allow their slaves to terminate pregnancies. The owners wanted their slaves to produce as many children as possible since these children belonged to the slave owners. This situation persisted until the end of the slavery era.
Abortion: need, services and policies: Maryland.
The provision of abortion services in the state of Maryland for the year 1977 is described. The number of women in need of abortion services, provision of services since the 1973 Supreme Court decision, how well the women in need are being served, the prevalence of Medicaid-funded abortions and characteristics of women obtaining abortions is reviewed along with United States and state laws and policies related to abortion. Priorities for abortion service development are outlined, and counties in Maryland are reviewed and ranked according to the level of abortion need which has been met. The following were included among the findings: 1) there were 23,700 abortions reported in Maryland in 1977; 2) most women obtaining abortions in Maryland were young (71% were younger than age 25); 3) 46% of women in need were unable to obtain abortion services in Maryland; 4) the abortion occurrence rate in 1977 in Maryland was 23.7 abortions/1000 women of reproductive age (15-44); 5) during fiscal year 1977, 6000 abortions were funded by Medicaid; 6) Maryland is continuing to fund abortion services for Medicaid-eligible women; 7) provision of abortion services is heavily concentrated in the states's metropolitan areas; 8) the majority of the abortions in the state in 1977 were performed in 11 non-hospital clinics and physicians' offices; 9) abortion services were available in only 32 of the state's 50 hospitals; 10) 16 of the state's 24 counties had abortion providers which reported at least 1 abortion during 1977 or the 1st quarter of 1978; and 11) the rate of abortion in Maryland is lower than that in the United States as a whole.
The public health need for abortion statistics.
The right of states to make abortion reporting mandatory is defended. The public's need for information on abortion is of sufficient importance to override individual privacy rights. Demographic and medical data on abortion, collected by the Center for Disease Control (CDC) since 1967, provides a basis for 1) assessing the health risks involved in abortion; 2) identifying those procedures which are associated with the least risk of morbidity and mortality; 3) evaluating the quality of services provided by various types of abortion facilities; 4) identifying those populations most in need of contraceptive services; and 5) predicting future demands for abortion services. The CDC receives most of its abortion data from the central health agency of each state. However, for some states, the data is collected directly from hospitals and other facilities involved in providing abortion services. In the future the National Center for Health Statistics will collect all abortion data for CDC. The CDC not only collects abortion data but also analyzes the data in terms of the morbidity and mortality risks associated with abortion. Some of the findings based on the analysis of the data are 1) complication rates through the 20th gestation week are lower for dilation and evacuation procedures than for instillation methods; 2) the number of abortion related deaths declined from 88 in 1972 to 44 in 1975; 3) the risk of death increases as gestational age increase; and 4) abortion to live birth ratios are highest for women in the oldest and the youngest age categories. Statistical information on abortion has also facilitated judicial and legislative decision making in abortion relation matters.
In 1974-1975 a national survey was conducted in 120 villages and 11 towns and cities throught Upper Volta for the purpose of acquiring information on internal and international migration patterns. The major population flow occurred in the Mossi area. A large numbers of Mossi women migrated to the rural areas in other parts of the country while large numbers of Mossi men migrated to the Ivory Coast. The Upper Volta served as a labor pool for the agricultural plantations in Ghana and the Ivory Coast. 2/3 of all the wage earners in the Ivory Coast were migrants from Upper Volta. Rural to urban migration was also common. Approximately half of the urban population was composed of migrants. 22% of the people interviewed in the survey had migrated at least once. 4 types of migration patterns were identified. These patterns were 1) the migration of young, unmarried men, seeking temporary employment and planning eventually to return to their communities of origin; 2) the migration of women, upon marriage, to the village of their husbands; 3) the migration of young people to urban areas for educational purposes; and 4) the migration of young children to towns, where they live with other families and either assist these families with household tasks or attend school. The government could stem the flow of migrants from the rural areas by improving rural employment opportunities and by helping farmers purchase farm equipment.
School achievement: risk factor in teenage pregnancies?
New York State Health Department statistics pertaining to live births, spontaneous fetal deaths, and induced abortions were used to analyze trends in teenage pregnancy among upstate New York white and nonwhite females, aged 12-17, from 1971-1974. An unexpected finding was that students, in some age and race categories, with either below average or above average school achievement, measured by the highest grade completed at delivery or abortion, were at greater risk of pregnancy than students with average school achievement. White girls, who were 12-13 years old and who were either below average or above average in school achievement, had an excess number of pregnancies; those who were 14-15 years old and above average in school achievement, had an excess number of pregnancies; and those who were 16-17 years old and below average in school achievement, had an excess number of pregnancies. Nonwhite girls, who were 12-13 years old and above average in school achievement, had an excess number of pregnancies, and those who were 14-17 years old and below average in school achievement, had an excess number of pregnancies. Other findings were 1) the number of live births remained relatively constant for both nonwhites and whites from 1971-1974; 2) the number of induced abortions increased from 1971-1974, especially among nonwhite teenagers; 3) the number of pregnancies increased for all age and racial groups from 1971-1974 except for 12 year old white females; and 4) among whites, aged 12-15, and among nonwhites, aged 12-13, the number of induced abortions surpassed the number of live births. Tables provide 1) the distribution of teenage pregnancies by school grade and 2) the number of live births, induced abortions, spontaneous fetal deaths, and the pregnancy rate/1000 years of risk by age and school grade for whites and nonwhites, aged 12-17, from 1971-1974. Bar graphs depict the number of abortions and live births by age and grade for white and nonwhite teenagers, 1971-1974.
[Risks and benefits of hormonal contraceptives]
This chapter considers risks and advantages of 3 methods of hormonal contraception: postcoital, injectable, and oral contraception. Postcoital contraception consists in the administration of massive doses of estrogen, usually diethylstilbestrol, within 48 hours of coitus. This treatment is often associated with nausea and vomiting. Menstrual regulation is another form of postcoital contraception. Injectable contraception consists in injections of medroxyprogesterone acetate every 3 months. It is very effective but related with potential carcinogenic effects; its most common side effect is menstruation disorders. Oral contraception (OC) is by far the most effective, with a failure rate of only 0.5-5/100 women-year. It is well known that several and serious complications are related to OC. Such complications can be related to dosage, but also to such variables as ethnic, educational, and nutritional characteristics of acceptors. Many studies have demonstrated that there is no relationship between OC and breast, ovarian, or cervical cancer, while the association between OC, thrombosis and liver dysfunctions seems to be better documented. OC patients have 6.9 times more probability of developing hypertension. The minipill is indicated for patients who react negatively to estrogen; main side effects are nausea, vomiting, and irregular menstrual cycles. Its effectiveness is not as good as that of combined oral contraceptives.
[Super-suppression Syndrome or Post-pill Syndrome]
There is no doubt that oral contraception (OC) can inhibit ovulation, although there is no clear correlation between duration of OC and seriousness and length of hypothalamic suppression. The author conducted retrospective studies on 1800 patients complaining of infertility or sterility. Of these 41.5% presented alterated ovulatory factors, and 12.5% had been on OC, mostly for over 6 months. The great majority of patients were between 26-30, 71.2% had normal cycles, 4.40% had amenorrhea, and 24.4% other menstrual dysfunctions. Many had monophasic cycles, proliferative endometrium, and negative cristallization of cervical mucus. After treatment, mostly with clomiphene, 70.7% of patients with monophasic cycle became biphasic, 42.1% of anovulatory cycles became ovulatory, there was a positive cristallization of the cervical mucus in 86.6% of patients, and 37.2% of proliferative endometria evolved to good progestational activity. Finally, 43.1% of patients became pregnant.
[Sociodemographic characteristics in 3 age cohorts]
This chapter investigates the age of the woman as the biologic variable directly influencing her fecundity. Such factors as education, socioeconomic status, job or profession were also taken into consideration as social variables. 3 groups of women were considered: between 40-49, between 25-39, and between 15-24. Older women and women from rural areas had a higher parity than others. Method of birth control seemed to depend strictly on the age of the woman; induced abortion was the most used method for older woman, who not only did not know any preventive method, but were very strict in their attitude against preventive birth control. Information on contraceptive methods seemed to come mostly from friends, family, and especially from husbands. Only women in the younger age group recurred to doctors. Younger women had also a different and positive attitude toward birth control, and tended to discuss such problems with their partners. Communication on fertility control should be made easier and certainly more widespread. Radio and television could be used, but especially classes of formal instruction on sex education, particularly in certain regions of the country.
[Biological aspects of fecundity]
Object of this investigation was to study the distribution of gestations, and of their results, as related to age of parents and to the use of contraception prior to gestation. A total of 2555 women were considered, with a total of 8880 gestations. 15% of women had had 1 gestation, 24.9% 2 gestations, 16.6% 4 gestations, 2.3% 8 gestations, and 1 woman had had 21 gestations. 36.3% of gestations were unwanted, since the mother was, at the time, using a contraceptive method. Contraception was used at every age; before the first gestation less than 20% of women used it, after the first gestation 35-60% used it, and the percentage augmented at every successive gestation. Contraceptive methods used were, in decreasing order, coitus interruptus, condom, and vaginal jelly in every age group. Of the total number of gestations 80.6% resulted in live births, 11.8% in spontaneous abortions, and 1.4% in stillbirths. The rate of spontaneous abortions and of stillbirths increased with age and with number of gestations, but was not related in any way to previous contraceptive use.
[Health and protection of human rights]
Induced abortions raise many differences of opinion in relation to the human rights: the right of the fetus to live is sometimes in conflict with the mother's right to health. In the countries where induced abortion has been legalized, doctors hesitate to perform an abortion after the 12th week of gestation. Children born with congenital abnormalities such as microcephalia or Down's syndrome raise very difficult ethical problems. It is generally believed that the parents should make the decision concerning their child; the doctor must explain to them as clearly as possible the consequences of the various choices. In several countries voluntary sterilization is authorized for reasons oth er than health, providedcertain conditions are fulfilled. In some countries it is possible to sterilize a subject with mental retardation or with a mental disease, while in other countries such an act is considered as a criminal offense to the human rights. The transformation of the human environment has affected particularly older people who find themselves isolated when not rejected. The highest suicide rates for men start with retirement, and for women around the time when their role as mothers comes to an end.
Comparison of prostaglandin F2alpha and hypertonic saline for induction of midtrimester abortion.
20 healthy women between 18-20 weeks of gestation and seeking abortion were studied to compare the effects of prostaglandin F2alpha (PGF2) with those of instillation of saline solution and intravenous oxytocin. 9 out of 10 patients in the prostaglandin group aborted completely in about 15.16 hours. In only one of the prostaglandin patients did abortion have to be completed surgically. All of the 10 patients in the saline solution-oxytocin group also aborted completely, but with a mean time of 22.34 hours, a difference not statistically significant. The complication rate was higher in patients aborted with PGF2, including postabortion lactation and gastrointestinal effects, especially vomiting. In terms of hormonal changes, the similarities between the 2 groups were more numerous than the differences, suggesting that the 2 mechanics of abortion may not be totally different. Comparative studies on a much larger group of patients are desirable.
[Abortion induction and the fetal alcohol syndrome (Letter)]
Abortion should not be automatically considered in the case of alcoholic mothers. Alcoholism is a social problem and an effort should first be made to solve the case of an alcoholic mother with the social programs offered by mental institutions and the like.
[Abortion law in practice (Editorial)]
The Law on Abortion and Sterilization became effective on March 12, 1975. To evaluate the effects of the law, one cannot rely on plain statistics or personal impressions alone. Both must be combined in the form of a scientific study to research the consequences of the abortion law.
Abortion statistics for Sweden in 1976 are presented. The liberalized abortion law passed in 1975 caused an increase in the number of abortions performed, but an increase in the incidence of abortion is apparent as early as 1974. This would indicate that a more liberal attitude toward abortion coincided with the 1974 proposal to liberalize the abortion law. 32,351 abortions were performed in 1976, compared to 32,526; this may indicate that a peak has been reached in the demand for abortion. Between 1971 and 1976, the percentage of abortions performed up to the 12th week of pregnancy and the percentage of abortions performed in open wards increased.
Abortion (amendment) bill. [Letter]
Your editorial of Jan. 26 and the multi-signatory letter in your issue of Feb. 2 support the 1967 Abortion Act and suggest that Mr. Corrie's Bill is a retrograde step. The implication is that our professional knowledge should lead us to that conclusion. To take the opposite view risks being regarded as a member of a pressure group or a conscientious objector, but to remain silent might be construed as being in agreement. As I see it the great majority of people of varying ethnic groups, including those adhering to the Jewish, Muslim, and Christian faiths, subscribe to a behavioral code which regards human life as sacred: to take a life is to be countenanced only to save another. Abortion should be regarded as taking human life and morally wrong; making abortion legal does not make it morally right. Doctors are in a very difficult position, and cannot, no more than politicians can, make moral decisions for other people. Traditionally, however, the profession has a role in the responsibility for protection of life, and perhaps the public have a right to expect this protection. Human life begins at conception and some human rights begin at this time. Life (and its protection) seems to be a most basic right. The World Medical Association, in the Declaration of Oslo (1970), stated: "1. The first moral principle imposed upon the doctor is respect for human life as expressed in a clause of the Declaration of Geneva: 'I will maintain the utmost respect for human life from the time of conception.'" The 1967 Abortion Act did not result from a general referendum, much less a medical referendum. If the Corrie Bill is passed and abortions are cut by 2/3 as you suggest, this would, in my view, be a step, not back, but in the right direction. (Author's)
Abortion (amendment) bill. [Letter]
Several doctors prominent in the British Medical Association say that Mr. Corrie's Bill should be opposed. They are entitled to their views, but they cannot speak for the profession as a whole in this matter. As a B.M.A. member who opposes termination of pregnancy as incompatible with the doctor's role in protecting life, I firmly support the Bill. The B.M.A. should realize that doctors are individually responsible for those actions which have ethical/moral dimensions. We cannot hide behind the skirts of an ethical committee, and the B.M.A. should not use its privileged position to influence Parliament in such matters, especially since legislation affects future generations of doctors whose views we do not know. After all, only 30 years ago a straw poll of the profession would almost certainly have opposed the widespread abortion carried out today; a return to this way of thinking is quite possible. B.M.A. News Review (December, 1979) states that "no true doctor would wittingly destroy a life that has a chance of surviving"--and yet that is exactly what many doctors are doing. Can I make a simple plea that we as doctors return to sanity and stop our support for the illusion that just because a life is still intrauterine it carries few rights. (Author's)
The use of high concentration oxytocin intravenous drips in the management of missed abortion.
18 cases of missed abortion occurring during or after the 12th week of gestation in Professor Kellar's Unit of the Simpson Memorial Maternity Pavilion during the past 3 years were managed using intravenous high concentration oxytocin drips. Estimated duration of fetal death ranged from 3 to 14 weeks. A summary of the results of analysis is presented in Table 1. Delivery was achieved in the last 13 cases (except 2) within 24 hours of treatment. Of the 2 exceptions, 1 patient in whom the fetus had been dead for the longest time (14 weeks) took 31 1/4 hours to pass the fetus; the other patient took 21 1/4 hours to pass the fetus but as the placenta failed to follow, another drip was administered 11 hours later. The placenta was passed 50 minutes later. Surgical evacuation of the uterus was performed in 7 patients to complete the abortion process. No evidence of failure of clotting mechanism after delivery was observed, nor was the possibility of toxic substances being introduced into the maternal circulation from the placenta seen. It was concluded that the use of oxytocin drips is a reliable, rapid and safe method of managing missed abortion.
Prostaglandins, indomethacin and dysmenorrhea.
Prostaglandins (PG) have been implicated in the pathogenesis of primary dysmenorrhea either by increased synthesis of PG in the uterus or an enhanced sensitivity to PGs in the myometrium. Reports show that prostaglandin synthetase inhibitors such as indomenthacin administered orally 3 times/day provides complete or marked relief to dysmenorrheic women. This study examines uterine contractility and plasma levels of PG of dysmenorrheic women treated with indomethacin. 9 volunteers with severe primary dysmenorrhea were studied. Uterine contractility was measured using a 0.1 ml capacity microballoon tied to a polyethylene catheter and connected to a Stratham pressure transducer and a Grass polygraph. Plasma levels of endogenous PGs were measured using gas chromatography-mass spectrometry method. Uterine recordings were repeated during subsequent menses following pretreatment with indomethacin 75 mg or 200 mg/day beginning 1 day before onset of the menses. Indomethacin was orally administered at a dose of 25 mg x 3 in 3 subjects and 50 mg x 4 in 2 subjects 1 day before expected menses and until the 3rd day. 100 mg was administered rectally in 1 and 2 women without dysmenorrheic symtoms served as controls and were given 100 mg indomethacin on the 1st and 2nd day of menses. All indomethacin-treated cycles had a lower uterine tonus, with 6 subjects experiencing complete alleviation of spasmodic pain. The endogenous concentration of 15-keto-13, 14-dihydro PGF2a was found to be relatively high in dysmenorrheic women. It is hoped that more effective synthetase inhibitors, or even better, organ specific drugs, may soon become available in the future.
A double-blind crossover study was conducted to compare the analgesic effect of paracetamol; acetylsalicylic acid; and placebo on dysmenorrhea. 30 nulliparous female medical, pharmacy and dental students were studied for 3 consecutive menstrual cycles. All subjects were randomly assigned in 5 blocks with all 6 possible combinations of the 3 drugs represented once in each block; they were to take 1 tablet/day for 3 days as soon as bleeding started. A visual analogue scale measuring 10 cm and which ran from 'no pain' to 'pain as bad as it can be' measured pain relief; blood loss was measured using a Perometer (AB Ljungberg and Co., Stockholm, Sweden). The results show that neither acetylsalicylic acid (0.5 g x4) nor paracetamol (0.5 g x4) proved effective; the placebo effect was very small. Higher drug dosages might have provided a better effect (Layes Molla and Donald). The side effects experienced by the patients could not have been drug-induced, as there was no difference between the 2 drugs and the placebo in the incidence of side effects, and all reported side effects belong to the symptomatology of dysmenorrhea. Acetylsalicylic acid has been associated with excessive bleeding during and after surgery; epistaxis; hemorrhagic complications in newborn infants; and adverse effects on hemostasis. It does not affect blood loss during menstruation, however.
Cluster of abortion-related complications--Texas.
During the August-8-October 14, 1977 period, 5 women with septic complications following abortion were admitted to a south Texas hospital. 1 of the women died with septicemia and renal failure. Review of the hospital records at the 270-bed community facility showed that only 1 case of septic complications following abortion had been admitted during the previous year. 2 more women had had such complications but were not admitted. All 5 of the women had had abortions in Mexico. All the women were of Hispanic descent; 4 were United States citizens. Endometrial and/or blood cultures from 3 of the women grew C. perfringens organisms; a 4th patient had tetanus. 3 of the patients were Medicaid recipients. Details of the fatal case are included.