Correlation of fetal age and measurements between 10 and 26 weeks of gestation.

Fetal measurements, especially fetal foot length, were correlated with fetal age--as measured by last menstrual dates--for 1800 tissue specimens obtained after dilatation and evacuation abortion. These observations were compared with Streeter's results from 1920. Fetal ages ranged from ten through 26 completed menstrual weeks. Fetal measurements including weight, knee-to-heel length, biparietal diameter, placental weight, and amniotic fluid volume were correlated with foot length. Sonographic biparietal diameter obtained by real-time imaging was correlated with tissue measurement of biparietal diameter for various fetal ages. The difficulties of establishing valid correlations are discussed, and a table of recommended values for fetal measurements by week of fetal age is provided.

Serial multiple laminaria and adjunctive urea in late outpatient dilatation and evacuation abortion.

The safety and clinical approach in late second-trimester outpatient dilatation and evacuation abortion is controversial. In this series, 1000 dilatation and evacuation abortions were performed on patients from 17 through 25 menstrual weeks' gestation in a private office outpatient facility. Each patient experienced serial multiple laminaria treatment over two days before abortion. Patients at 20 weeks' gestation or more also received adjunctive urea amnioinfusion on the day of the procedure. Three patients (0.3%) experienced major complications. Although a wide variety of clinical problems was encountered, procedure times were short, blood loss was generally low, and other complication rates were low. Recommendations for staffing and the prevention of complications are discussed.

Outpatient abortion for fetal anomaly and fetal death from 15-34 menstrual weeks' gestation: techniques and clinical management.

OBJECTIVE: To determine the safety of providing outpatient abortion services for women with complicated advanced pregnancies. METHODS: During a 10-year period, 124 abortions were performed after 14 menstrual weeks' gestation at an outpatient abortion facility for indications of fetal anomaly, diagnosed genetic disorder, or fetal death. Gestational lengths ranged from 15-34 menstrual weeks. Fetal diagnoses included a variety of chromosomal abnormalities, malformations, and death. Techniques for performing the late abortions included a serial multiple laminaria method of cervical dilation. Abortions performed after 20 menstrual weeks were effected by instillation of intra-amniotic hyperosmolar urea or induction of fetal death by injection of digoxin and/or hyperosmolar urea into the fetus, followed by artificial rupture of membranes, induction of labor, and assisted expulsion or instrumental extraction of the fetus. At less than 20 weeks, dilation and evacuation following serial multiple laminaria treatment of the cervix was the method of choice. RESULTS: The median gestational age was 23 menstrual weeks. The median procedure time for all cases was 12 minutes and median blood loss was 125 mL. Procedure time increased with length of gestation (P = .00). Blood loss was only slightly increased by gestation length (P = .154) and not by procedure time (P = .299). Complication rates were not significantly related to gestation length (P = .895). There was one major complication in this series. There were no uterine perforations and one cervical laceration. CONCLUSION: Outpatient abortion may be performed safely in most cases of fetal disorder, including death, through 34 menstrual weeks under proper conditions.

Life on the front lines.

PIP: A physician who owns and operates an abortion clinic in Boulder, Colorado, in the US relates how he came to offer this procedure to women and how this choice has affected his life. The physician had worked as a medical student at a Schweitzer-inspired hospital in the Peruvian Amazon in 1964 and later as a Peace Corps physician in Brazil. He performed his first abortion in 1970, in Washington, D. C., for a 17-year-old high school student whose future plans would have been derailed by her pregnancy. At that time, the physician was working to change the federal government's restrictions on abortion funding and he began to correspond with abortion rights groups and heard the Supreme Court arguments in the landmark abortion cases. As part-time medical director of a family planning training program in the Rocky Mountain region, part of his job was to provide information about new abortion techniques. In 1973, he was asked to help start an abortion clinic in Boulder, and he accepted the position of medical director reporting to an executive director. He had to struggle to acquire privileges at Boulder Community Hospital in order to admit patients with complications. In addition, a "Fight the Abortion Clinic Committee" tried to have the clinic closed by the Colorado Board of Health. Further obstacles were placed by members of the Boulder County Medical Society who formed another committee with the intent of closing the clinic. After a tour of the clinic, the committee chairman declared that the clinic met the highest standards of medical care, so that effort was ended. In November 1973, antiabortion groups began to picket the clinic and the physician began to receive threatening phone calls at home. He purchased a rifle and kept it by his bed. In the summer of 1974, he participated in a debate on Denver television. He had to be secreted out a back door after a subsequent debate. The same summer, the Denver chapter of the National Organization for Women held a rally to honor those who advanced the cause of women's rights. They honored the physician who had to shout over hecklers to make his remarks heard. After a year of operation, the physician encountered differences with the Board of Directors of the clinic. Soon after that, he resigned and opened his own clinic with a bank loan of $7000. Within 4 years, his clinic had expanded, and he purchased its building. The harassment from antiabortion protesters continued, with broken windows, pickets, and, in February 1988, bullets fired through the front windows of the waiting room. This necessitated the installation of bullet-proof glass and a security system which cost $17,000. As of March 1, 1993, there had been 1285 acts of violence towards abortion clinics, which led to the destruction of more than 100. On March 10 of that year, a physician who performed abortions in Florida was gunned down by an anti-abortion protestor. People who provide abortions hope for legal protection and respect for their civil liberties, but they will continue to provide this service even if conditions do not improve.^ieng

Life on the front lines.

PIP: Warren Hern's reminiscences about his experiences as medical director of the Boulder (Colorado) Abortion Clinic and as an abortion provider in private practice provide support for his statement, "Every doctor in America who does abortions lives under a death threat." Shortly after the clinic was opened, a group of anti-abortion physicians pressured the Boulder County Medical Society to pass a resolution declaring the clinic a "clear and present danger" that should be shut down by local health boards. As the only freestanding abortion clinic in the state in the mid-1970's, the Boulder center was targeted by the Right-to-Life Committee picketers and Dr. Hern was harassed in his home and in public. When Dr. Hern left the clinic a year later to establish a private practice specializing in pregnancy termination, the picketers followed. After release of a textbook he prepared on abortion practice, the publisher was deluged with hate mail and threats of boycott, leading them to withdraw the text from its list. Violent attacks on abortion clinics accelerated after Reagan's election and bullets were fired into Hern's waiting room. Randall Terry, national head of Operation Rescue, prayed for Hern's death at a rally in front of his clinic. By the time Dr. David Gunn was assassinated by an anti-abortionist in March 1993, there had been over 1285 acts of violence against abortion facilities and more than 100 facilities had been completely destroyed. The transgression for which Dr. Gunn was murdered was that he sought to save the lives and futures of countless women and support their right to become full participants in society.^ieng

Laminaria, induced fetal demise and misoprostol in late abortion.

OBJECTIVES: To analyze and determine the safety and effectiveness of induced fetal demise as an adjunctive method in outpatient abortion for patients with advanced pregnancies and to evaluate the independent effect of intrauterine misoprostol administered after amniotomy in late abortion. METHODS: During a 9-year period, 1677 abortions were performed for patients whose pregnancies ranged from 18 through 34 menstrual weeks in an outpatient facility. Of these, 832 were performed by one physician. Techniques for performing all the abortions included induction of fetal demise by intrauterine fetal injection of digoxin and/or hyperosmolar urea, serial multiple laminaria treatment of the cervix, amniotomy, oxytocin induction of labor, and assisted delivery or surgical evacuation of the fetus and placenta. In the last 411 of the 832 patients whose abortions were performed by one physician, misoprostol was placed in the lower uterine segment following amniotomy in order to enhance labor induction, cervical ripening, and fetal expulsion. RESULTS: Of the entire group of 1677 cases, the median gestational age was 22 menstrual weeks. The median procedure time for all cases was 10 min. Measured median blood loss was 125 ml. Blood loss and procedure time increased with length of gestation, but these were not affected by misoprostol. There were three major complications (0.2%) in the overall series. Among patients seen by one physician (N=832), amniotomy-to-procedure time was shorter by 26 min for patients receiving misoprostol, and there was 27% more variability in amniotomy-to-procedure time among patients not receiving misoprostol. Complication rates for patients receiving misoprostol were the same as for those not receiving misoprostol. There were no major complications in the 832 patients seen by one physician, no uterine rupture or perforations, and no cervical lacerations. CONCLUSIONS: Outpatient abortion may be performed safely from 18 through 34 menstrual weeks using combined surgical and medical procedures. Use of intrauterine post-amniotomy misoprostol was associated with reduced amniotomy-to-procedure time and reduced variability in the amniotomy-to-procedure time.

Health and demography of native Amazonians: historical perspective and current status.

Native Amazonians have been the victims of two massive historical assaults, one at the time of the Conquest and the other during the Twentieth century. Due to epidemic disease and environmental destruction, many tribes have gone from contact to displacement, decimation, and extinction in a single generation. Deculturation and the construction of large development projects have had catastrophic effects on native populations. In many ways, native Amazonians have experienced a reverse of the "Epidemiologic Transition". Paradoxically, one of the effects of cultural disruption for some native Amazonians has been the loss of cultural controls on fertility with the result that high fertility has become a major health problem. Combined with rapid growth of non-indigenous Amazonian populations, deforestation, and urbanization, native Amazonians face grave obstacles to long-term survival.

How Roe v. Wade has shaped my life and work.

PIP: For several years prior to the US Supreme Court's decision in Roe vs. Wade, the author of this account, the Director of the Boulder Abortion Clinic, had been working for the legalization of abortion. After the decision was announced, he thought that the political problem surrounding abortion had been solved and that the only remaining problem was how to implement the decision through the development of rational policy and safe standards. Another challenge he recognized was the social legitimization of abortion services. In 1973, he helped open the first free-standing nonprofit abortion clinic in Colorado and performed all of the abortions. In 1975, he opened the Boulder Abortion Clinic, which soon became the site of anti-abortion demonstrations and violence. Anti-abortion harassment contributed to the dissolution of his marriage, and the windows of his office were shattered by gunshots. Operation Rescue officials publicly called for his assassination, and one of his colleagues was, in fact, killed. Thus, the Roe decision had a personal impact on this physician's life that he would never have anticipated.^ieng

Midtrimester abortion.

PIP: The principal methods of midtrimester abortion are induction of labor or surgical evacuation. Induction of labor includes mechanical stimulation with a catheter, bougie, or metreurynter; amnioinfusion methods, either with hypertonic saline solution, hyperosmolar urea, or PGF2alpha; and pharmacological stimulation, either with PGF2alpha suppositories, or intramuscular injection of 15-methyl PGF2alpha. Surgical evacuation includes hysterotomy, now almost completely abandoned unless in special circumstances, and dilatation and evacuation (D&E). In 1972 D&E was the predominant method used in abortion in the 13-15 week interval, with 73.3% of cases, while it accounted for only 16.7% of interventions in the 16-20 week period. Cervical dilatation can be done with laminaria in a variety of different protocols. D&E procedures require skill and experience, time, and an array of different instrumentation. Midtrimester pregnancy must be carefully evaluated prior to intervention by pelvic examination, sonographic examination, and laboratory tests. Individual counseling of patients by a trained abortion counselor is very helpful. Complications associated with amnioinfusion procedures include failed abortion, gastrointestinal effects, bleeding, perforation, cervical laceration and infection. This study includes a detailed description of operative technics in D&E abortions at fetal ages from 11-12 weeks, to 21-22 weeks. Complications associated with D&E are failure to dilate, trapped calvarium, fragmented placenta, hemorrhage, perforation, cervical laceration and infection. Major complication rates for D&E and saline instillation are 0.69 and 1.78/100 abortions, respectively, at 13-16 weeks. Major complications with PGF2alpha instillation are 1.6 times the risk with saline infusion. Incidence of risk increases after 16 weeks gestation. D&E procedures can at times be very demanding for the assisting staff.^ieng

Has the human species become a cancer on the planet? A theoretical view of population growth as a sign of pathology.

The author describes current global population trends as being similar to the development of a cancer in the living body. "The human species, through the instrument of culture, has become the dominant force of planetary ecological change. Our adaptations have become maladaptive. Moreover, the human species as a whole now displays all four major characteristics of a malignant process: rapid, uncontrolled growth; invasion and destruction of adjacent normal tissues (ecosystems); metastasis (distant colonization); and dedifferentiation (loss of distinctiveness in individual components). We have become a malignant ecopathologic process. If this diagnosis is true, what is the prognosis? The difference between us and most forms of cancer is that we can think, and we can decide not to be a cancer."

Laminaria versus Dilapan osmotic cervical dilators for outpatient dilation and evacuation abortion: randomized cohort comparison of 1001 patients.

OBJECTIVE: Our purpose was to compare the clinical experience in using Dilapan osmotic dilator and Laminaria japonicum as overnight osmotic cervical dilators in second-trimester dilation and evacuation abortion with respect to measurable outcome variables, including complication rates. STUDY DESIGN: A cohort comparison was performed of 1001 patients receiving alternate preoperative treatment with either osmotic dilator after initial randomization until this number had been reached in the series. RESULTS: Few significant differences were found in the two cohorts with respect to blood loss, procedure times, and overall complication rates. However, patients receiving the Dilapan dilator were at least twice as likely to experience problems in cervical dilation or problems resulting from poor dilation or disintegration of the device than were patients receiving Laminaria japonicum. Although more patients receiving laminaria experienced amniotic fluid embolism or disseminated intravascular coagulation syndrome, these problems could not be attributed to the type of osmotic dilator used. CONCLUSION: Both osmotic dilators are acceptable for use in overnight dilation in this procedure, but the Dilapan dilator is more likely to disintegrate, retract, or present minor problems associated with poor dilation.

Individual fertility rate: a new individual fertility measure for small populations.

Fertility measurement in small preindustrial societies is hampered by small numbers and the lack of some essential data. Most measures of fertility are collective and require large enough populations to permit grouped data analysis. Existing individual measures of fertility are often unsatisfactory. This paper presents a new measure of individual fertility, the Individual Fertility Rate (IFR), which is constructed by dividing parity by reproductive span in years and multiplying the product by 100. The result is a number which may be used as a dependent individual or cumulative variable to study the effects of health and socioeconomic factors on fertility.

First and second trimester abortion techniques.

PIP: This issue focuses on 1st and 2nd trimester abortion techniques, postabortion procedures and follow-up, and the management of abortion complications. The objectives of the monograph are to discuss clinical abortion technique in adequate detail to permit the practitioner to review the surgical technique step by step and to understand the means by which the safest possible results can be secured. The emphasis is on operative techniques throughout the range of abortion practice from 6-24 weeks gestation. The emphasis is on abortion performed as an outpatient procedure involving the use of laminaria and local anesthesia. It is noted that good surgical technique encompasses accurate preoperative diagnoses and evaluation, a high level of operator skill, sound sterile technique, atraumatic surgical technique, thorough removal of devitalized tissue, and careful postoperative supervision and follow-up. The degree to which complications arise is inversely related to the serious attention given to these principles. Unlike 1st trimester abortion, in which suction curettage has emerged as the method of choice, midtrimester abortion requires more individualized evaluation. Among the methods presented in this monograph are amnioinfusion and dilatation and evacuation.^ieng

Laminaria in abortion. Use in 1368 patients in first trimester.

PIP: Use of laminaria for dilatation in 1368 patients obtaining first trimester abortion in a private clinic, Boulder, Colorado is described. Median age of patients was 21 years, 39% had had previous pregnancies, and 18.1% had had previous abortions. For 68 (4.8%) this was the 2nd abortion within 1 year. 65% of gestations were 5-8 weeks, 10% under 5 weeks, 18.1% from 9 to 10 weeks, and 4.6% 11 weeks or more. 9.4% of laminaria procedures had secondary manual dilatation. This was related to experience. 20 cases occurred in the 1st 102 procedures while a substitute physician who performed 42 procedures had a rate of 28.5%. The remaining 1224 cases had a secondary dilatation rate of 8.3%. Techniques for adequate placement of the laminaria and procedures to follow in cases of uneven dilatation are described in detail. Most common complication was fever of 102 degrees F or less for less than 1 day (58 cases). In 4 cases severe cramps resulted, leading the patient to extract the laminaria at home. There was 1 serious complication, a pelvic abscess. Principal disadvantages include the necessity for 2 clinic visits, the risk of mild to severe overnight cramping, expense (laminaria used cost $2.75 each), and anxiety, generally unfounded, about whether the patient would return the next day. Advantages are reduced need for local anesthesia with decreased likelihood of anesthetic reaction, reduced risk of uterine perforation and cervical laceration due to decresed need for forceful dilatation, rapid procedure time, and reduced blood loss. Also it allows some careful preoperative evaluation of the patient's emotional state and her feelings about the abortion and pain. The complication rate in this series was 8.3%, most minor.^ieng

Cervical treatment with Dilapan prior to second trimester dilation and evacuation abortion: a pilot study of 64 patients.

PIP: A trial of the synthetic hygroscopic cervical dilator Dilapan (Gynotech Inc.) in 64 women having 2nd trimester dilation and evacuation abortion is reported. The women were clients of an outpatient abortion clinic in Boulder, Colorado, from December 1985 to February 1986. Their gestational ages were 13-25 weeks, their ages 15-41 years, and 59% were nulliparas. They had 1-5 Dilapan dilators, dipped in nitroufurazone ointment, placed intracervically the day before the procedure after preparation of the cervix with povidone-iodine solution. The number of dilators was that which could be inserted easily. 14% received 1 dilator, 64% had 2 dilators, 22% had 3, and 1 woman had 4. 3 women had the dilators removed and replaced 6 hours later because of discomfort. Women who were over 20 weeks' pregnant received urea intraamniotically. Dilapan dilators were left in place from 6-30 hours. Before abortion adequate cervical dilation was obtained manually as needed. The length of the abortion procedure ranged from 2-22 minutes and was proportional to gestational length. Blood loss averaged 118 ml (range 5-500 ml), also related to gestation. The number of dilators placed was not correlated with length of the procedure or blood loss. There were several minor complications related to the Dilapan dilators: disintegration of the dilators in 2 women, retraction into the internal os, expulsion of the dilators, rupture of membranes during insertion, "dumbelling" of the dilators, and 15 cases of inadequate dilation after one dilator. Several women had cramping, felt to be due to the rapid expansion of these synthetic dilators. Despite these problems, Dilapan dilators were considered safe.^ieng

Cultural change, polygyny, and fertility among the Shipibo of the Peruvian Amazon.

PIP: Household interview in 8 Shipibo communities on the Ucayali and Pisqui Rivers in Peru in 1983 and 1984 were conducted in order to obtain reproductive histories of 386 women aged 13 years and older. Polygyny was defined in three ways: as ever experienced, as operant during a specific birth interval, and as the mean length of closed birth intervals and the proportion polygynous. The aim was to determine the effect of the decline in polygyny on increased fertility. The results showed that of 1445 individuals in 8 villages, 585 (over 33%) lived in Paoyhan village. The sex ratio was 104 men to 100 women and varied among the villages. 49.3% were younger than 15 years and 60.3% younger than 20 years. Crude birth rates varied from 42.6 to 89.6/1000. Crude death rates ranged from 14 to 63.8/1000. Infant mortality was 138/1000. The village of 9 de Octubre had the lowest compared fertility and also had the highest rate of polygyny. Irazola village had the highest man completed fertility, and the lowest polygyny. The median reported age at marriage was 14 years; median reported age at menarche was 13 years. Age at menarche was the same regardless of marriage type, but polygynous women tended to marry about a year earlier. First delivery averaged about 15.6 years and was lower for polygynous women. 75 (19.4%) had ever engaged in a polygynous unions. The highest polygynous unions were in 9 de Octubre, Vencedor, Tupac Amaru, and charashmanan villages, and ranged from 56.5% to 5.3%. The proportion of men in polygynous unions ranged from 3.4% in Paoyhan to 21.9% in Vencedor. 84.5% of women aged 15 years and older had had at least one pregnancy. The mean reproductive span was 13 years. The mean age at delivery was 28.8 years. The mean birth interval was 31.5 months; mean interval for women aged 45 years and older was 36.2 years. There was found no correlation between birth interval number and birth interval length, or mother's age at birth interval and length of birth interval. Polygynous unions had a mean birth interval length 4 months longer, and lower fertility: 4.7 births versus 6.0 births. Regression analysis showed a straight line positive correlation between mean birth intervals and polygyny, even excluding Paoyhan, and a negative relationship between the prevalence of polygyny and fertility.^ieng

United States government policy on abortion.

PIP: Federal government policy in the United States lacks uniformity, as is indicated by the fact that the Dept. of Defense permits the performance of abortion for medical and mental health reasons, the Office of Economic Opportunity states that no project funds may be used for any surgical procedure intended to result in abortion, and the Dept. of Health, Education and Welfare has no policy concerning abortion in its programs but that abortion is a reimbursable expense under Title XIX Medicaid payments in enrolled states. This ambiguity of the federal government is considered a reflection of the complexity of the issue and the lack of clear consensus concerning abortion among the American public. Factors that federal family planning officials must consider are: 1) the ethical and moral considerations that confront the individual citizen making a private decusion about abortion; 2) legal and constitutional issues, such as that of discrimination in the availability of abortion services on economic grounds; and 3) the relationship of abortion to public service needs and public health considerations, given that 1/4-1/5 of pregnancies in the United States end in legal or illegal abortion. Clandestine abortion constitutes a significant health problem, accounting for a significant proportion of maternal mortality, especially among the poor (the 1967 rate of reported mortality due to abortion with sepsis being 7 times greater for nonwhites than whites). The Office of Economic Opportunity in reassessing its current policy needs to ascertain the standards of medical care, cost projections, and logistics of providing abortion services. It is recommended that abortion services be combined with serious efforts to provide effective subsequent contraception, as abortion as an exclusive method of birth control would cost up to $2000 per year while the provision of high quality family planning services is $60-$80 per woman per year.^ieng