Kwak, Hyun M.

Moon, Young K.

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2. SUBJECT CLASSIFICATION (695)BIBLIOGRAPHIC DATA SHEET 1.CONTROL NUMBER fAc)&Y C.cX6)> O 3. TITLE AND SUBTITLE 240) 4. PERSONAL AUTHORS (100) 5. CORPORATE AUTHOR3 (101) 6. DOCUMENT DATE (110) 17. NUMBER OF PAGES (120) 8. ARC RUM IWT0­9. REFERENCE ORGANIZATION (130) 10. SUPPLEMENTARY NOTES (500) .cr'\o, I (5--8c, 7T I7 /?c<o) 11. ABSTRACT (950) 12. DESCRIPTORS (920) 13. PROJECT NUMBER (150) F32 o oc& .c37 14. CONTRA CT NO.(]4n) 15. CONTRACT TYPE (140)IM/'c 6t -7f -,1 16, TYPE OF DOCUMENT (160) AD 590-7 (10-79) INSTRUCTIONS 1. 	Control Number - Each document shall carry a unique alphanumeric identification number. Use uppercase letters, Arabic numerals, and hyphens only, as in the following example: PN-AAA-123. 2. 	Subject Classification - Each document shall carry a valid subject classification code used to classify the research/technical document under a general primary subject, secondary subject, and/or geogra­phic index code. 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AID 590-7 (10-79) back FS 1 02 Timing of Laparoscopic Sterilization in Abortion Patients HYUN MO KWAK, MD, YOUNG KI MOON, MD, CHAN HO SONG, MD, DONG WON AHN, MD, AND I-CHENG CHI, MD, DrPH A total o( 1604 laparoscopic sterilization procedures with variable time intervals after first trimester therapeutic abor-tion were performed at the Severance Hospital of the Yonsei University College of Medicine, Seoul, Korea, from May 1973 to October 1975. Two hundred fourteen women were sterilized immediately at the time of abortion; 359 were sterilized between 1 and 42 days later; and the re­maining 1031 women were sterilized 43 or more days after abortion. Electrocoagulation and tubal ring application were the tubal occlusion techniques used. The findings in-dicate that patients who underwent the combined abor-tion-sterilization procedure did not encounter higher rates of technical problems and/or complications than the other 2 groups. Only a few of these 1604 women studied had po­tentially serious complications that necessitated sub-sequent laparotomy, hospitalization after sterilizztion, and/ or hospital readmission. Either first trimester therapeutic abortion or lap-aroscopic sterilization can be performed safely on an outpatient basis. The motivatiun to accept a per-manent contraceptive method such as sterilization usually is high when a woman requests a therapeutic abortion. Thus, there are many logistic and program-matic advantages to performing the 2 procedures at the same time. However, whether or not the combined procedures are medically justified is still subject to controversy.'- 4 Although some investigators appear to favor the combined approach,'14 their results must be viewed with reservation, as the results were compared with those of laparoscopic sterilizations performed on nonpregnant women in other institutions, and compli-From the Severance Itospital of the Yonsei University College ofMed-icine, Seoul, Korea, and the International Fertility Research Program, Research Triangle Park, North Carolina. This work was supported in part by the International Fertility Re-search Program and the Office of Population, United States Agency for InternationalDevelopment (AID/pia-C-1172). Submitted for publication October 25, 1979. cation rates resulting from laparoscopic sterilization differ markedly in different centers. This report documents the authors' experience in 1604 women who were sterilized using laparoscopy at variable intervals after first trimester therapeutic abor­tion. The outcome of women who underwent the com­bined abortion-sterilization procedure was compared with those who underwent sterilization some time af­ter the therapeutic abortion to determine whether the combined procedure was associated with a higher risk of technical problems and complications. Materialsand Methods A total of 1806 first trimester therapeutic abortion pa­tients were sterilized using single-puncture lap­aros.opy from May 1973 through October 1975 at the Severance Hospital, Yonsei University College of Medicine, Seoul, Korea. Standardized forms were used for recording pertinent sociodemographic char­acteristics of the patients, medical aspects of the pro­cedure, surgical difficulties, complications, and other relevant events during and after the surgery. One thousand six hundred four (1604) healthy subjects who were sterilized for family planning purposes were included for study after excluding those patients with systemic diseases, previous abdominal surgery, pelvic pathology, or other concurrent surgery. The study pa­tients were divided into the following 3 groups with respect to the timing of sterilization relative to thera­peutic abortion: 1) those who underwent sterilization immediately after abortion (postabortion group, 214 patients); 2) those who undenvent sterilization from 1 to 42 days after abortion (intermediate group, 359 pa­tients); 3) those who underwent sterilization at least 43 days after abortion (interval group, 1031 patients).Electrocoagulation with tubal division and tubal ring application were the 2 tubal occlusion techniques used. vOL.[198opment 56 NO.1,JUY t v VOL. 56, NO. 1, JULY 1980 Obsrt,;)!r. rvy yecR'r iI Deveop 0029-7844/80/070085-05$01.75 85 Foom 105 SA.18 ::- , 1"'- 20523 For the postabortion group, the concurrent preg-nancy of all 100 patients sterilized by the electro-coagulation technique was terminated by vacuum as-piration/curettage. Among the 114 patients sterilized by the tubal ring technique in the postabortion group, pregnancy was terminated by vacuum aspiration/cu-rettage in 56 patients and by dilatation and curettage in the remaining 58 patients. For the intermediate and interval groups, pregnancy was terminated exclusively by vacuum aspiration/curettage. The laparoscopic sterilization procedures per se were performed in essentially the same manner in all 3 groups. For electrocoagulation sterilization, the 2-burn technique was used, and the tubes were divided. For tubal ring sterilization, I ring was applied on each tube. All the surgery was performed by the teaching staff on an outpatient basis. In most patients, the sur-gery was done using local anesthesia (10 to 15 ml of 1%procaine) with neuroleptic analgesics (50 to 100 mg pethidine hydrochloride and 10 rng diazepam) admin-istered 5 minutes before the procedure. Fifty-two postabortion and 31 interval patients sterilized by the tubal ring technique, as well as 5 interval patients who underwent the electrocoagulation procedure, were op-erated on using general anesthesia. The patients usually rest2d for 2 to 4 hours after surgery before leaving the clinic. Three follow-up vis-its after surgery were scheduled: at 7 to 21 days, 6 months, and 12 months. All patients returned for the 7- to 21-day follow-up. Analysis was performed by comparing the 3 groups of patients who underwent the same tubal occlusion tecinique in terms of their sociodemographic charac-teristics, immediate complications (during or immedi-ately after the procedure and before discharge), early c.-mplications (those reported at the 7- to 21-day fol-low-up visit), and other relevant events such as surgi-cal time, surgical difficulties, readmission, and preg-nancy. For qualitative variables (eg, proportion of patients with I or more complications), X2 tests were used; for quantitative variables (eg, surgical time in minutes), analysis of variance was used to determine whether differences among the 3 groups were statisti-cally significant (P < .05). Results For those who underwent electrocoagulation or tubal ring application, the mean age, mean parity, and per-cent of patients who were overweight generally were comparable among the 3 groups. The postabortion group was, however, significantly better educated than the other 2 groups (Table 1). Among those sterilized by electrocoagulation, the immediate complication rate was 2.0% in the post­abortion group, 2.8% in the intermediate group, and 1.9% in the interval group. The complications in the postabortion and intermediate groups were of a minor nature. However, major complications occurred in 4 patients in the interval group: 1had excessive bleeding from the tube that required emergency laparotomy; 2 had bowel injuries, I of which required laparotomy; and 1 had a uterine perforation caused by the uterine manipulator. No early complication was experienced in the postabortion group. The early complication rates were 2.3% in the intermediate group and 4.6% in the interval group. Fever requiring antibiotics and in­cision wound infection were the most frequently re­ported complications. No serious early complication was experienced (Table 2). The differences a.nong the 3 groups of either immediate or early complications were not statistically significant. Among those who underwent tubal ring application, the immediate complication rate was 3.5% in the post­abortion group, 3.3% in the intermediate group, and 5.7% in the interval group. The corresponding early complication rates in the 3 groups were, respectively, 3.5%, 1.7%, and 2.8%. There was no serious immediate or early complication, and pelvic pain or cramps were the most common problems among the 3 groups (Table 3). No significant differences were detected among the 3 groups concerning the incidence of either immediate or early complications. Surgical time for the laparoscopic procedure was counted in minutes from the initial incision through fi­nal closure. Time spent during the therapeutic abor­tion in the postabortion group was not included. The mean surgical time spent on the electrocoagulation procedure among the 3 groups ranged from 10.5 to 11.6 minutes. In those sterilized by tubal ring appli­cation, the laparoscopic procedure ,equired a longer time (14.7 minutes) in the postabortion group than it did in the other 2 groups (9.4 minutes for intermediate and 10.2 minutes for interval groups). The difference is statistically significant. Difficulties in laparoscopic procedure were encoun­tered in 5 cases. The cause of the difficulty in I post­abortion patient was obesity and the causes in the 4 interval patients were obesity (2 cases) and difficulty in visual"Ling the tubes due to unsuspected pelvic adhe­sion (2 cases). Only 3 patients, e.ih sterilized by electro­coagulation, were hospitalized after the procedure, I in the postabortion group and the other 2 in the inter­val group. Also, 3 patients were readmitted: 1 with a tubal ring in the postabortion group (due to severe pelvic pain); I who had undergone electrocoagulation 86 Kwak et al Laparoscopic Sterilization and AbortionGJbsh'trics & Gynecology Table 1. Sociodemographic Characteristics Characteristics Electrocoagulation method Mean age (years) Mean parity Mean education (years)* Percent overweight Tubal ring method Mean age (years) Mean parity Mean education (years) Percent overweight Postabortion Intermediate Interval group group group (N = 100) (N = 177) (N = 525) 34.1 33.4 34.3 3.1 3.3 3.3 11.5 9.2 9.8 5.0 5.7 4.4 (N = 114) (N = 182) (N = 506) 34.4 33.9 34.9 3.3 3.4 3.4 11.0 8.7 9.4 1.8 3.3 4.6 * Difference between postabortion group versus intermediate and interval groups is statistically signif­icant at P < .05. in the intermediate group (due to severe abdominal pain; laparotomy revealed a hematoma in the caute- rized site of the left tube); and 1 who had undergone electrocoagulation in the interval group (laparotomy was performed to repair a bowel injury that was not found during the procedure). Patients were followed for 6 months or longer in 75% of the postabortion, 79% of the intermediate, and 80% of the interval group. Three pregnancies occurred in the postabortion group (1 pregnancy was probably due to failure of the vacuum aspiration/curettage to evacuate the conceptus), none in the intermediate group, and 4 in the interval group (1 woman had con­ceived prior to sterilization). All were intrauterine pregnancies. Discussion It has been suspected that the pelvic changes that oc­cur during pregnancy may increase technical problems and/or complications if laparoscopic sterlization is combined with pregnancy termination. 6 One investi­gator, however, argued that significant varicosities in mesosalpinx are generally not encountered until 16 Fable 2. Immediate and Early Complications/Complaints in Electrocoagulation Patients Immediate complications/complaints" Excessive bleeding requiring laparotomy Bowel injury Requiring laparotomy Not requiring laparotomy Uterine perforat'on Mild mesosalpinx bleeding Subcutaneous/subperitoneal emphysema Anesthesia complication No. of patients with L, I immediate complications Early complications/complaintst Fever requiring antibiotics Incision wound infection Pelvic pain/cramps Spotting from incision wound Nausea/vomiting No. of patients with 2 1early complications Postabortion Intermediate Interval group group group (N = 100) (N = 177) (N = 525) 0 0 1 0 0 1 0 0 1 0 0 1 1 3 1 1 2 5 0 0 1 2 (2.0%) 5 (2.8%) 10(1.9%) 0 3 12 0 3 16 0 1 1 0 0 1 0 0 1 0 (0.0%) 4 (2.3%) 24 (4.6%) Complications/complaints that occurred during or immediately after the sterilization procedures. t Complications/complaints that occurred during the 7- to 21-day follow-up. 0 VOL. 56, NO. 1, JULY 1980 Kwak et al Laparoscopic Sterilization and Abortion 87 Table 3. Immediate and Early Complications/Complaints in Tubal Ring Patients Postaborti-n Intermediate Interval group group group (N = 114) (N = 182) (N = 506) Immediate complications/complaint-* Excessive bleeding not requiring laparotomy Mild bleeding of mesosalpinx Subcutaneous/subperitoneal emphysema Pelvic pain/cramps 0 1 1 2 0 0 0 6 1 3 7 19 No. of patients with _>1 immediate complications 4 (3.5%) 6 (3.3%) 29 (5.7%) Early complications/complaints* Fever requiring antibiotics Incision wound infection Pelvic pain/cramps 1 0 3 0 1 2 6 2 8 No. of patients with -> 1 early complications 4 (3.5%) 3 (1.7%) 14 (2.8%) * Complications/complaints that occurred during or immediately after the sterilization procedures. t Complications/complaints that occurred during the 7- to 21-day follow-up. weeks' gestation.' All subjects included in this study were within 12 weeks' gestation at the time of thera-peutic abortion. The 3 groups, subdivided in this study according to the timing of laparoscopic ster-lization, were generally comparable in their biologic characteristics such as age, parity, and proportion with obesity. The study subjects were marked with a high incidence of previous induced abortion; more than half of all the subjects had had at least 3 previous in-duced abortions. The results revealed that for those undergoing elec-trocoagulation or tubal ring application, technical problems and major complications were rarely en-countered, irrespective of timing of the laparoscopic sterilization procedure. None of those complications that are theoretically more likely to be connected with concurrent pregnancy and/or abortion, such as exces-sive bleeding and uterine perforation, occurred in the postabortion group. The proportion of patients suffer-ing from 1 or more complications either during the wassterilization procedure or at the early follow-up not significantly higher in patients with the combined abortion-sterilization procedure than in those who were sterilized afterward. Of the total 1604 patients in-cluded in the study, no death was reported, and in only 2 patients (both of whom were in the interval )did the operators fail to complete the proce-group) The oero pail to coutere prc-dures. The number of patients who encountered surgi-cal difficulties during the laparoscopy, needed hospi-talization after the procedure, or required hospital readmission also was small and not clustered in any 1 of the 3 groups. Anesthetic methods used during laparoscopic steri­lizations were not entirely comparable among the 3 groups. Also, a few patients in the interval group had a concurrent endometrial curettage or aspiration to en­sure that there were no luteal phase pregnancies. However, if the comparisons are limited to those pa­tients operated on using local anesthesia, and if pa­tients in the interval group who underwent a con­current endometrial check are eliminated, the general findings do not change. One previous study4 has documented that patients undergoing laparoscopic sterilization combined with therapeutic abortion did not have a significantly higher complication rate than patients undergoing therapeutic abortion alone. In this study, the authors have shown that patients undergoing laparoscopic sterilization combined with therapeutic abortion did not have significantly higher rates of complications and/or technical problems than patients undergoing sterilization some time after therapeutic abortion. References 1. Amin HK, Neuwirth RS: Further experience with laparoscopic sterilization concomitant with vacuum curettage for abortion. Fertil Steril 24:592, 1973 2. Hernandez FM: Post-abortal laparoscopic tubal sterilization, re­suits in comparison to interval procedure. Obstet Gynecol 50:356, 1977 88 Kwak et al Laparoscopic Sterilization and Abortion Obstetrics & Gynecology 3. 	Purandare BN: Postpartum and postabortion sterilization. Int J Gynaecol Obstet 14:65, 1976 4. 	 Whitson LG, Ballard CA, Israel R: Laparoscopic tubal steriliza-tion coincident with therapeutic abortion by suction curettage. Obstet Gynecol 40:677, 1973Obstt973ResearchGyeco 40:77, 5. 	Courey NG, Horowitz AJ, Cunanan RG: Sterilization combined with abortion, Laparoscopy. Edited by JM Phillips. Baltimore, Williams & Wilkins, 1977, pp 182-186 6. 	Fishburne Jl, Edelman DA, Hulka )F, et al: Outpatient lap­aroscopic sterilization with therapeutic abortion versus abortion alone. Obstet Gynecol 45:665, 1974 Address reprint requests to: l-cheng Chi, MD, DrPH Epidemiologist InternationalFertility Research Program Triangle Park, NC 27705 Accepted for publication November 26, 1979. Copyright © 1980 by The American College of Obstetricians and Gynecologists. VOL. 56, NO. 1, JULY 1980 	 Kwak et al LaparoscopicSterilization and Abortion 89 

Timing of laparoscopic sterilization in abortion patients

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Timing of laparoscopic sterilization in abortion patients

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