In an analysis of 2287 cases of miscarriage including an unknown number of illegal abortions registered in Baltimore from 1896 to
1934, the average pregnancy length was 14 weeks measured from the LMP.42 Only women who were bleeding excessively or had infections were admitted to the hospital. Over 50% of those women had a gestation of above 16 weeks. The mortality was 1.7% in this cohort of women and the majority of deaths were attributed to infections, and in no instance was haemorrhage the immediate cause of death. The true number of criminal or illegal abortions was unknown, but 9% of the women admitted to having undergone such a procedure.
In the 1930s Collins managed 1304 cases of miscarriage medically with oxytocics. There were six deaths due to infection.43 He described 14 additional deaths during an earlier period with only one death due to haemorrhage, the rest being due to infections. Roussel treated 3739 cases of miscarriage between 1933 and 1944 with oxytocics and reported an average hospital stay of 14 days. There were 51 deaths, ten of them because of blood loss and the rest mainly again because of infection.12 It is reasonable to conclude that prior to the antibiotic era, infection and not haemorrhage was the predominant threat to women undergoing miscarriage.
To prevent miscarriage and other pregnancy problems such as toxaemia, premature delivery and intrauterine fetal death, about six million pregnant women were exposed to diethylstil-boestrol (DES) from 1940 until 1971. Fortunately, some of the users were included in controlled studies that showed that DES was of no value to prevent miscarriage, or in preventing any of the other conditions for which it was given. On the contrary, DES carried an increased risk of the patients' developing breast cancer, and for the offspring a higher risk of genitourinary malformations, psychiatric disorders and vaginal or cervical clear cell adeno-
In 2665 women treated surgically with a presumed diagnosis of miscarriage between 1934 and 1949 the mortality rate was 0.26%.13 Compared to historical controls, this mortality rate seemed to be low, indicating that active treatment was more effective than conservative management. In this study, the author had the impression that 90% of the miscarriages were in fact criminal abortions. Most of the severe complications were following douching, during which fluid was forcibly flushed into the uterine cavity. All the deaths were due to infec-tion.13 Soap bubble embolism was assumed to be the cause of some cases of sudden death, but these women never arrived at the hospital.31 In a survey in 1950 of 727 incomplete miscarriages treated actively by curettage, the women had an average hospital stay of 4.8 days with no mortality reported.48 This was a superior figure compared to women managed conservatively.31 It is, however, difficult to compare these four studies since penicillin, which came into use in 1945, was not available to Pecham's, Roussel's or Collins' cases, and morbidity and mortality was mainly related to sepsis. It is not surprising that surgical evacuation under these circumstances was seen as an adequate and sometimes life-saving treatment for women with symptoms of miscarriage, especially when criminal abortion could not be ruled out. Hertig and Livingston stated in 1944 that the treatment of miscarriage was a matter of emptying the uterus as quickly and as safely as possible. This general consensus prevailed for the last five decades concerning the superiority of surgical evacuation in cases of miscarriage.49-51
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