THE CLASSIFICATION OF MORBIDITY SYMPTOMS-LATENT MORBIDITY

26. Lembrych refers not only to cervical incompetence as a reason for the birth of more premature and light-weight babies, but also to damage to mucus membranes resulting in a variety of symptoms, at the time of confinement includ ing cases of faulty placentae. Other papers, including Lunow et al, and not only German papers," 10 30 refer specifically to damage to the endometrium resulting in defective implantation and in consequence to faulty development of the placenta. A recent American paper notes that damage to the endometrium and abortion are a part of the etiology of faulty development of the placenta and quotes four other papers in support." There are many papers associating such faulty development of the placenta with perinatal mortality and congenital handicap. Endometritis has therefore some consequences that may be described as latent that are only of importance to Class A women who wish to remain progenitive. Damage to the endometrium does not only result in the troubles at confinement listed by Lembrych, but prejudices the development of the placenta. The resulting placental insufficiency or defect may prejudice the development of the fetus. The complicated changes from the fertilization of the ovum to the end of the puerperium are prejudiced by types of injury to the reproductive organs that may not be noticed at all when these organs are passive. The sequelae of abortion are different when the reproductive organs are carrying a fetus subsequently than if they are not carrying a fetus. This may seem obvious, but is ignored in many papers on induced abortion thus making such papers relevant only to Class B women.

27. The Class A women who wish to remain progenitive will wish to take into account the possible consequences not only to themselves but also to a subsequent unborn child. It has also been taken into account that the risks to infants in the total sequence of human reproduction are much greater than to mothers. Perinatal mortality is more than one hundred times maternal mortality. The risk of damage to an infant's central nervous system is much more than one hundred times the risk of damage to the mother's.

LATENT MORBIDITY-ISO-IMMUNIZATION

28. This is another type of latent morbidity following induced abortion that is discussed in some detail in German papers. The risk is to subsequent children and is therefore another risk only of concern to Class A women. The risk depends on the blood groups of the father or fathers as well as of the mother, but also on the method of abortion used. The risk increases quite steeply with the number of pregnancies and is very low for a first pregnancy. The more preg nancies a women has aborted before she starts a family the higher the risk of iso-immunization to subsequent children.

23

29. The authors of a recent paper on serological incompatibility recom mend on these grounds alone that there should be no abortion if a later pregnancy is likely. The paper continues that if it is decided to proceed with an abortion nevertheless in spite of this advice then the consent of the husband should always be sought and the risks should be explained.

30. Asztalos et al analyse 267 cases of Rh (D) and ABO incompatibility. They compare the risks of feto-maternal iso-immunization following abortion by curettage and vacuum aspiration. They found a lower risk using vacuum aspiration but a risk nevertheless. The comparative risks of these methods of abortion as reported in some German papers are discussed further below. Asztalos et al (1972) quote 32 other papers, 28 in German, on iso-immunization. 31. Good protection against the consequences of iso-immunization in a subsequent pregnancy can be ensured for those Rh-negative women who are at risk by the injection of anti-D antibody following an induced abortion. This is considered good practice in all countries 24 25 26 and is practised by the British National Health Service. How far are women given this protection by the private abortion clinics? How far are the clinics required to provide this protection for Rh-negative women? A failure to take such prophylactic measures can lead not only to very difficult confinements but to still births and to some

19 Huntingford, P. J. (1971).

20 Palmer, R. (1972),

21 Weekes. L. R. & Greig, L. B. (1972).

22 Butler, N. R. & Alberman, E. D. (1969).

23 Asztalos, M., et al. (1972).

24 Browne, J. C., McClure and Dixon, G. (1970).

25 26 Freda, V. J., et al. (1971).

of the worst forms of human handicap in a child born subsequently. Induced abortion of a first pregnancy is reported to increase the risk at the next pregnancy from a very low figure to about 4 per cent."

LATENT MORBIDITY-STERILITY

32. The risk of sterility is yet another reason for distinguishing between Class A women who wish to remain progenitive and Class B women to whom sterility is no problem. Lunow et al (1971) give references to papers discussing sterility as far back as 1938. 29 30 German papers quote figures for the prevalence of sterility following induced abortion within the 2 to 5 per cent range quoted in the previous submission.

MORBIDITY FOLLOWING ABORTION BY VACUUM ASPIRATION

33. The vacuum aspiration technique has been introduced rather recently in the USA and United Kingdom. There are numerous papers in German that compare the morbidity resulting from use of vacuum aspiration with other techniques at different numbers of week's gestation. For example, Zwahr's paper mentioned above summarizes the results of 745 abortions between the years 1967 and 1969, a period when the particular hospital was transferring from the general use of curettage, that had been in use for many years, to the use of vacuum aspiration. This paper compares the subsequent short and long-term morbidity that resulted from the use of vacuum aspiration alone, from curettage alone and from vacuum aspiration followed by curettage when this was indicated. Before commenting on Dr. Zwahr's paper its predecessors should be mentioned. This particular paper gives 28 references, all in German. The earliest of these papers specifically describing vacuum aspiration and comparing the morbidity resulting from this technique with other techniques is dated 1964.32

33

34. The paper by Dr. Chalupa of 1964 is also extensively documented showing that there were already many papers on vacuum aspiration with comparisons of of other techniques already available at that date but mostly in Slavonic or other languages. The earliest paper quoted by Dr. Chalupa and other recent authors appears to be a Chinese paper reporting in 1958 on 300 cases where vacuum aspiration had been used. The next earliest paper on vacuum aspiration quoted was published in a gynecological journal in Latvia in Russian in 1961.** Papers on vacuum aspiration covering large trials were presented to a gynecological congress in Moscow in 1963. Quite a number of papers in Czech based upon trials were already available in 1964. The vacuum aspiration method is much older than these papers suggest and is described in Russian papers in the 1920's. There was even a book on the Soviet experience published in Germany in 1933.35 The continuity of recent experience does however only appear to go back to the Chinese paper of 1958. An Austrian paper summarized the world literature on abortion with particular reference to mortality and morbidity following legal therapeutic abortion in 1965.38 This paper, and indeed the earlier papers, have now been superseded.

35. However claims have been made recently in the USA and the United Kingdom for the vacuum aspiration technique and it is now increasingly widely used on both sides of the Atlantic. It is important therefore to appreciate that many variations of the vacuum aspiration technique 37 have been used in many countries and the results of many thousands of cases of its use have been reported in the medical journals over a period of at least 14 years.

36. Dr. Zwahr confirms the result of many other German papers. Vacuum aspiration leads to somewhat less complications than curettage, but has a substantial morbidity rate nevertheless. Taking only long-term complications the

27 Visscher, R. D. and Visscher, H. C. (1972).

28 Schultze, G. K. F. (1938).

29 Topp, G. (1959).

20 Dykova, H., et al. (1960).

31 Zwahr, Chr. (1972).

Chalupa, M. (1964) but see also Cislo, M., et al (1966); Willgerodt, W. & Birke, R. (1967); Birke, R. & Willgerodt, W. (1968); Flamig, C. & Schneck, P. (1969); Nemet, S. & Konja, Z. (1970); Weise, W., et al. (1970); Lunow, E., et al. 1971).

Wu-Yuan-T'ai & Wu-Hsien-Chen (1958).

34 Melks, E. I & Roze, L. V. (1961).

35 Mayer, A. (1933).

36 Heiss, H. (1965).

37 See Semm, K. (1972) for a recent paper on catheter design.

incidence was 14.4 percent when vacuum aspiration was used and 17.7 percent following curettage. Taking all cases where there were any kind of complications the total incidence was 31.8 percent following vacuum aspiration and 38.4 percent following curettage. The difference was statistically significant.

37. However the numbers of patients in Zwahr's series who suffered from each of the long list of complications were too small to provide statistically significant comparisons between the types of complication resulting from the different methods of abortion. It is noteworthy, however, that of all the late complications listed "endometritis" is the most important whichever method of termination is used and indeed more important than all the other long-term complications taken together. Following vacuum aspiration 7.3 percent and following curettage 10.7 percent of patients suffered from endometritis. This only repeats the importance of endometritis as a long-term complication following induced abortion emphasized by previous German papers, for example by Lembrych (1972) and other papers going back to Chalupa (1964) and further.

38. Dr. Zwahr concludes that abortion is not a safe and harmless operation whether or not vacuum aspiration is used and that it behooves every doctor who has the responsibility to weigh the risks carefully and only agree to an abortion if there is a strong medical indication.

39. The other German papers come to similar conclusions, for example Weise et al (1970) in discussing vacuum aspiration conclude that it is the best method if used early in pregnancy but "there is no harmless method".

40. Lunow et al reported 7.9 percent of early complications using vacuum aspiration on 683 patients and 18.9 percent of early complications on 514 patients using curettage and other methods, but that there was little difference between the prevalence of longer-term complications following vacuum aspiration and curettage which was higher at 36 percent of patients with complications but only of the 703 patients who were examined. The importance of the longer term morbidity is such that greater weight must be given to figures for longer term nor bidity. Seen as a whole the papers do no more than suggest that the vacuum aspiration method used early in pregnancy is somewhat less damaging than other methods.

41. The recent paper of Hoffman and Ziegel recording 4 percent of early complications rising to 15 percent of long-term complications using vacuum aspiration has already been mentioned. The complications are subdivided into the usual endometritis, endomyometritis, parametritis, and adnexitis.

42. A recent Swiss paper analysing 629 abortions comes to similar conclusions: * "The termination of a pregnancy is not a harmless procedure and this will remain so. Even for the simplest methods, the vacuum aspiration in early pres nancy, great care and experience are necessary."

Papers saying that great experience is necessary beg the question as to how the experience is acquired.

LATENT MORBIDITY-EXTRA-UTERINE PREGNANCY

43. Zwahr describes an abortion using vacuum aspiration that was followed by an ectopic or extra-uterine pregnancy with a fatal outcome. He then says that for this reason alone the material recovered should always be examined his tologically. A macroscopic examination is not always adequate. “Only a histological examination can recognize an early extra-uterine pregnancy." It might be thought that ectopic pregnancies are so rare that Zwahr's firm recommendation could be over-cautious. However liability to an extra-uterine or ectopic pregnancy is another form of latent morbidity following an induced abortion, according to a number of papers. The risk that Zwahr points to is probably very low soon after the liberalization of abortion. It becomes a matter of greater importance as the population of women who have already had one abortion increases and the number seeking second and third abortions increases.

HISTOLOGICAL EXAMINATION OF ABORTION PRODUCTS

14. Other authors also emphasize the need for careful and histological examination of the products of vacuum aspiration. Chalupa quotes different investigators as return muscle fibers in the products in from 1.5 to 20 percent of cases, Vacuum aspiration does not necessarily only remove the fetus and placenta but may also remove muscle fibers from the wall of the uterus. This is likely to cause endometritis and endomyometritis. Histological examination is desirable to see that any faulty application of the technique may be improved.

38 Stamm, H. (1972).

45. Several papers state that the authors found that vacuum aspiration did not remove fetal bones reliably after 10 or 11 weeks gestation.39 40 41 These three papers appear to agree that 10 to 11 weeks is borderline and that later than 12 weeks is certainly too late for the use of the aspiration technique. Another paper describes the unfortunate consequences of fetal bone fragments being left behind in the parametrium following an abortion."2 In 1970 in England and Wales there were 5,259 operations using vacuum aspiration at 13 weeks gestation or longer and 1,136 at 15 weeks or longer and the great majority of these operations was carried out on women under the age of 24.43 The examination of abortion products not only throws light on whether too much is being removed but also upon whether enough is being removed. The German papers suggest however that at 12 or 13 weeks gestation and longer it is difficult and may be impossible to remove the whole of a fetus by vacuum aspiration and bone fragments in particular are left behind. In a vaginal termination it is impossible to see exactly what is happening. The operation is partly blind. The examination of the products therefore provides useful indirect evidence and may point, for example, to the need to supplement the aspiration with curettage. There is no wholly reliable way of determining accurately how many weeks of pregnancy have passed especially if the patient has been tutored to deceive the doctor. It is not practicable to limit the use of the vacuum aspiration technique to a very precisely defined part of the period of gestation such as the first 11 weeks.

CONCLUSIONS

46.1 The earlier submission by Margaret Wynn in May, 1972 came to a number of conclusions. This supplementary study of further papers, mainly in German, suggests that these conclusions were right but did not go far enough. 46.2 Problems of information retrieval and communication are familiar in many branches of science and technology today. Much existing knowledge about abortion is not available to the busy general practitioner or gynecologist in a form in which it can possibly be used. It must be assumed that it has become too difficult and expensive for the writers of books or articles in medical journals on abortion to keep up to date or follow the world literature. However, the retrieval of existing knowledge is much cheaper than new research repeating work already done elsewhere. Ignorance may also be costly in casualties. Most of the papers reviewed in the present paper describe casualties among women and subsequent children following induced abortion. Disregard of what these papers say is likely to result in a repetition of much of this experience but with British women and children as casualties. The Committee should consider how the accumulating knowledge about abortion can be made available to all those people to whom it can be of use and should recommend the amount of Government support that may prove necessary.

46.3 All persons concerned in any way with maternity or abortion services should be made aware of the 1963 recommendation of the British Perinatal Mortality Survey team and of Dr. Monro in 1966.“ 44 45 All women who have had

a previous abortion should invariably be booked for hospital delivery under consultant care. Such women should, however, also receive special ante-natal care from the end of the first trimester and all women who are possible future reproducers should be so informed at the time of the abortion with reasons adequate to persuade them to seek early ante-natal care in a subsequent

pregnancy.

46.4 Morbidity details and prevalence data based upon only short surveillance of women following an induced abortion are of very limited value. Only studies involving surveillance over long periods, including the period of any subsequent pregnancies, will add substantially to knowledge and understanding. It is suggested that the latent morbidity, not diagnosable until the occurrence of another pregnancy, should have absolute priority in studies financed by the Department. It is further suggested that for the better organization and co-ordination of such research that all maternity services should be required to notify the Department of all women reporting for ante-natal care who have had a previous abortion, and

Nemet. J. & Konya, Z. (1970).

40 Hoffmann, J. & Ziegel, E. (1972).

41 Birke. R. & Willgerodt, W. (1967).

42 Friz. M. (1964).

Registrar General's Statistical Review of England and Wales for 1970, Supplement on

Abortion.

Butler, N. R. & Bonham, D. G. (1963) p. 32.

Monro, I. C. (1966) p. 13.

to provide the Department with such information about the course of the pregnancy as may be required for the furtherance of the research.

46.5 Risks to subsequent children from iso-immunization should be reduced as far as possible by making prophylactic injections a required preventive measure wherever indicated by examination of a patient's blood prior to an abortion.

REFERENCES

The following references are to papers used in preparing this submission. This is a small selection from some hundreds of papers on abortion in the German language. One recent book on the Sociology of Abortion has been added but has not been used in the submission (Siebel, et al. (1971).)

Asztalos, M., Szabo, S. & Aszodi, L. (1972), “Einfluss der interruptions methode (Kürettage v Aspiration) auf die Feto-maternale isoimmunisation", Zül. Gynäk. 94:926-930.

Barter, R. H. (1967), "The Incompetent Cervix”, in Advances in Obstetrics and Gynecology, Vol. I, Williams & Wilkins.

Birke, R., & Willgerodt, W. (1968), “Zur Technik der vaginale Schwangerschaftsunterbrechung mittels Vakuumexhaustion", Zbl. Gynäk. 90:243.

Browne, J. C. McClure, & Dixon, G. (1970), Browne's Antenatal Care, J. & A. Churchill.

Butler, N. R. & Alberman, E. A. (1969), Ed. Perinatal Problems. E. & S. Livingstone.

Butler, N. A. & Bonham, D. G. (1963), First Report of the Perinatal Survey, E. & S. Livingstone.

Cee K. (1964), “Zur klinischen Problematik der einzeitigen instrumentallen Schwangerschaftsbeseitigung”, Zbl. Gynäk. 86:524.

Chalupa, M. (1964), “Gebrauch des Vakuum zur kunstlichen Schwangerschaftsunterbrechung", Zbl. Gynäk. 86:1803.

Cislo, M., Nowosad, K. & Reszczynski, A. (1966), "Schwangerschaftsunterbrechung mit Hilfe einer Saugapparatur", Zbl. Gynäk. 88:156.

Czeizel, A., Bognar, Z., Tusnady, G., Revesz, P. (1970), "Changes in mean birth weight and proportion of low-weight birth in Hungary", Brit. J. Prev. Soc. Med., 24:146.

Dykova, H., Havranek, F., & Pospisil, J. (1960), “Rückfluss des Blutes in die Eileiter als Mögliche Ursache der Sterilität nach Fehlgeburth", Zbl. Gynäk. 82: 1228.

Flamig, C. & Schneck, P. (1969), "klinische Erfahrungen bei der Schwangerschaftsunterbrechung mit dem Vakuumexhaustor", Zbl. Gynäk. 91:1567.

Freda, V. J., Gorman, J. G., Galen, R. S. & Treacy, N. (1971), "The need for anti-G following abortion" in Abortion Techniques and Services, Proc. of Conference New York, June 3-5, 1971, Excerpta Medica.

Friz, M. (1964), "Fetale Knochenreste im Parametrium als Folge Forcierter Abortusausräumung", Zbl. Gynäk. 86:1809.

Hansen, E. (1960), "Cerebral Palsy in Denmark", Acta Psychiatrica et Neurologica Scandinavica, Supp. 146. Vol. 35.

Heiss, H. (1965), Beburtsh. u Frauenheilk, 25:862. See also Heiss, H. (1967). Die Abortsituation in Europa und in Aussereuropäischen Ländern, Enke Veriag, Stuttgart.

Hoffmann, J. & Ziegel, E. (1972), “Klinische Erfahrungen bei der Schwangerschaftssunterbrechung mit dem Vakuumexhaustion und dem Metranoikter”, Zыl. Gynäk. 94:913-917.

Hofmann, D. (1968), "Statistische Untersuchungen über einige geburtshilfliche Zusammenhänge, speziell der Susammenhang von Fehlgeburten und späteren Nachgeburtskomplikationen", Zbl. Gynäk. 87:1537.

Huntingford, P. J. "Les Consequences Precoces et Tardives de l'Avortement Provoque", in Problèmes Politiques et Sociaux, No. 94-45, p. 67, special number entitled La Legislation de L'Avortement dans le Monde, La Documentation Francaise.

Lembrych, St. (1972), "Schwangerschaftsgeburts- und Wochenbettverlauf nach künstlicher Unterbrechung der ersten Gravidität", Zbl. Gynäk. 94: 164–168. Lunow, E., Isbruch, E. & Hamann, B. (1971), “Gynäkologische Frühkomplikationen als Folge legaler Schwangerschaftsunterbrechungen", Zbl. Gynäk. 93:49. Mayer, A. (1933), Erfahrungen mit der Schwangerschaftsunterbrechung in der Sowjetrepublik, Enke Verlag, Stuttgart.

Melks, E. I. & Roze, L. V. (1961), Novoe v. Akuserstve i ginekologii, Riga.