20.

That women who have had a previous abortion should be regarded as high risk cases in a subsequent pregnancy was the subject of a recommendation in 1963 in the report of the British Perinatal Mortality Survey.) In 1966 Monro, basing himself on the Survey, wrote in a book intended for the guidance of pregnant women and published by the National Birthday Trust Fund:(2)

"The Survey showed that there is an increased risk to the
babies of mothers who have a previous history of abortion or
ectopic pregnancy. Previous abortion increased by about
one-third the risk that the mother will lose her baby. This is
true no matter whether the abortion was a miscarriage, whether
it was done in hospital for medical reasons, or outside illegally."

The 1963 recommendation was that a woman with a previous history of abortion should be regarded as a high risk patient and should be "invariably booked for hospital delivery under consultant care." It is now apparent that this recommendation is right but not quite adequate and that it is also important to ensure expert ante-natal care from about the 12th week of pregnancy. This makes it quite essential that all women who have had an abortion and may wish to carry a subsequent pregnancy to term should know to seek ante-natal care early and should know the reasons for doing so. Class A women need to know much about the risks and particularly the latent morbidity risk, that is of much less significance for Class B women.

The argument in this paper for early, priority, ante-natal care for all women who have had a previous abortion is based so far on the likelihood of cervical incompetence following an induced abortion. This is not the only reason, however, for placing such women in the high risk category as discussed further below.

THE CLASSIFICATION OF MORBID SYMPTOMS FOLLOWING
INDUCED ABORTION - APPARENT MORBIDITY

21. One recent paper from Berlin University medical school() analyses what is described as the
"early complications" following 1,234 abortions induced at two Berlin clinics. The restriction to a
discussion of "early complications" is included in the title of the paper and the importance of this
restriction is explained at some length. The authors of this paper came to the same conclusions
as the authors of other more recent papers(),(3) that the prevalence of morbidity following
induced abortion reported by many writers depends upon how long the women concerned are kept
under surveillance after the operation. The longer the surveillance the higher the morbidity
reported. Lunow et al found 12.2 per cent of "early complications" in Berlin. They were only
able to obtain reports subsequently on 703 women, or 57 per cent of the original 1,234 women, at
varying times after they were discharged from hospital. There were 36 per cent of the 703
women with "longer term complications". Hoffmann and Ziegel recorded 4 per cent of "early
complications" and 15.5 per cent of "long-term complications". There is much lack of precision
in the use of "early", "short-term" and "long-term". Zwahr records 35.6 per cent of complica-
tions and explains his high figure compared with that reported by some other hospitals partly by
a concentration in his hospital of the more difficult maternity cases of the Schwerin district but
also by the unusual length of time for which his team deliberately followed the cases and the
unusual care with which the women were examined.

22. Length of surveillance is therefore a major factor influencing the amount of morbidity reported. There are papers both in German and in English that give prevalence figures for morbidity following induced abortion without any details, or even any broad indication, of the length of surveillance of the patient after the operation. Such papers not only add little to what is known but also can be misleading. Some clinics lose sight of their patients very soon after the operation and never see them again so that the period of surveillance is minimal.

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

(2) Monro, L. C. (1966) p. 13.

(1) Lunow, E. et al (1971)

() Zwahr, C. (1972).

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

The morbidity reported is then also likely to be minimal and bear little relation to what would be discovered if the patients were followed for five years. The requirements of the Department of Health & Social Security that complications should be reported to the Department by "the operating practitioner" within one week rules out any period of surveillance likely to result in the diagnosis of most of the post-abortion morbidity.

23. Lunow et al expressly exclude from their study what has been described above as latent morbidity or in their words the "pathological consequences of abortion during subsequent pregnancy and childbirth". They also exclude other types of latent morbidity expressly, including sterility, extrauterine pregnancies and serological incompatibility which are discussed further below and provide further arguments for distinguishing between Class A and Class B women in counselling and in policy. Lunow et al record 26 cases, or about 2 per cent, of cervical lesions, but comment that damage to the cervix is "commoner than is diagnosed" and quote an earlier paper expressing the same view. Cervical incompetence is essentially latent.

24.

The apparent morbidity, as distinct from this latent morbidity, is subdivided in nearly all the German papers into endometritis, endomyometritis, adnexitis, parametritis describing inflamation, infection, or damage to pelvic organs that is sometimes apparent soon after operation but more often much later. Intermittent or chronic ill-health may result. The literature reports many cases of such ill-health being brought to an end by hysterectomy. The restoration of good health by these means, is, of course, only available to Class B women and not to Class A women who wish to remain progenitive.

25.

There are no grounds for assuming that there are no long-term psychiatric sequelae of abortion particularly in those cases where there are physical sequelae or a latent morbidity becomes apparent in a subsequent pregnancy. The value of psychiatric studies of abortion that are based on short periods only of surveillance or that fail to distinguish between Class A and Class B women is questionable. As noted above Class A women must be told that they must be regarded as high risk obstetric cases in a subsequent pregnancy. This will increase anxiety during subsequent pregnancies even if the outcome is normal.

THE CLASSIFICATION OF MORBIDITY SYPTOMS

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 including cases of faulty placentae. Other papers, including Lunow et al, and not only German papers, ()() 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. (5) 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.

(·) Cee, K. (1964).

(2) Huntingford, P. J. (1971)

(2) Palmer, R. (1972)

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

(*) Butler, N. R. & Alberman, E. D. (1989).

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 to be 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 pregnancies a woman has aborted before she starts a family the higher the risk of iso-immunization to subsequent children.

29.

The authors of a recent paper(:) on serological incompatibility recommend 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(),(),() 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 of the worst forms of human handicap in a child born subsequently. Induced abortion of a first pregnancy is

pregnancy from a very low figure to about 4 per cent eported to increase the risk at the next

I wish to remain progenitive and Class B women to whom sterility is (),() German papers quote

32. The risk of sterility is yet another reason for distinguishing between Class A women who no problem. Lunow et al (1971) give references to papers discussing sterility as far back as 1938. 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 weeks' 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,

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

(2) Browne, J. C. McClure & Dixon, G. (1970).

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

() Visscher, R. D. & Visscher, H. C. (1972).

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

() Topp, G. (1939).

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

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.

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 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. (s) 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.() 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 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 incidence was 14.4 per cent when vacuum aspiration was used and 17.7 per cent following curettage. Taking all cases where there were any kind of complications the total incidence was 31.8 per cent following vacuum aspiration and 38.4 per cent 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 per cent and following curettage 10.7 per cent 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.

(-) Zwahr, Chr. (1972).

(2) 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).

Lanow, E. et al (1971).

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

(-) Melks, E. L& Rose, L. V. (1961).

() Mayer, A. (1933)

(-) Heisa, H. (1985)

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

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 per cent of early complications using vacuum aspiration on 683 patients and 18.9 per cent 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 per cent 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 morbidity. Seen as a whole the papers do no more than suggest that the vacuum aspiration method used early in preg nancy is somewhat less damaging than other methods.

41. The recent paper of Hoffmann and Ziegel recording 4 per cent of early complications rising to 15 per cent 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:(1)

"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 pregnancy, 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

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 histologically. 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

44. Other authors also emphasize the need for careful and histological examination of the products of vacuum aspiration. Chalupa quotes different investigators as return muscle fibres in the products in from 1.5 to 20 per cent 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 or endomyometritis. Histological examination is desirable to see that any faulty application of the technique may be improved.

45. Several papers state that the authors fo) These three papers appear to agree that 10 to found that vacuum aspiration did not remove fetal bones reliably after 10 or 11 weeks gestation.

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 () Stamm, H. (1972).

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

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

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