Miscarriage or Abortion and Premature Labor

The Terms ‘Miscarriage’ and ‘Abortion’ The loss of the baby during pregnancy before it is far enough along in its development to survive outside the uterus (viable) is called ‘miscarriage’ by most laymen. Doctors term it ‘abortion.’ As in a normal birth, the fetus is evacuated from its home in the uterus and expelled through the vagina. Until recentiy it was common practice to distinguish between abortion and miscarriage. ‘Abortion’ was the term for the very early variety, before the embryo has actual form, and ‘miscarriage’ the term for the later variety, after the embryo begins to resemble a baby. Medicine now uses ‘abortion’ to refer to both.

Laymen often make another distinction, using the term ‘miscarriage’ for involuntary abortion and ‘abortion’ for that which is artificially induced. Again the medical sciences make no such distinction. In their eyes any pregnancy terminated before the fetus is developed to the point at which it can possibly live after its birth is an abortion, no matter when it occurs or how it comes about.

Spontaneous Abortion

Ten per cent of all pregnancies—one in ten—terminate spontaneously before the fetus is of sufficient size and development to survive. The ordinary borderline between possible salvage of a baby and its likely demise after birth when born alive is 1000 grams—2 pounds, 3 ounces. This weight is normally attained between the twenty-seventh and twenty-eighth weeks of pregnancy. Of course, I do not mean to indicate that all babies above this intrauterine stage and weight survive, nor necessarily that all below succumb.

Most abortions or miscarriages occur long before this period of pregnancy; actually three in four happen before the twelfth week, and only one in four during the sixteen weeks between the twelfth and twenty-eighth weeks.

Factors Influencing Incidence

While we still do not completely understand the causes of abortion, they are much better known than they were even a few decades ago.

In a study that my colleagues and I made, we found that three conditions are associated with a low frequency of abortion: youth, ability to conceive immediately, and the absence of previous abortion. A woman under twenty-five who conceives within three months after she first tries to become pregnant and who has never aborted before is the most likely to leave a hospital nine months later with a baby. In this group the chances of abortion are only four in one hundred.

At the other extreme are the older women (more than thirty-five years of age) who require six months or longer to conceive and who have had an abortion. In this group the chances of miscarrying are forty in one hundred. Notice, this still leaves sixty who will bear their babies. And the forty who miscarry can try again and perhaps the next time be among the lucky sixty instead of the unlucky forty.

By finding out why a particular patient miscarries, the doctor may be able to prevent a recurrence. This is the reason that when you have symptoms of impending abortion your doctor will ask you to save any tissue expelled. If he cannot analyze it himself, he will send it to one of several special laboratories, where the material will be examined and a report sent him.

Some causes of abortion are related to the physical condition of the mother: fibroid tumors of the uterus, deep tears of the cervix (mouth of the womb) following a previous birth or abortion, extensive operations on the cervix, or con- genital malformations of the reproductive organs (misshapen uterus or cervix from infancy). Such illnesses as chronic high blood pressure, diabetes, syphilis, and severe malnutrition may also cause abortion.

In some cases the illness or malformation may be remedied and a subsequent pregnancy carried to full term. But many perfectly healthy and normal women miscarry, and miscarry repeatedly. Our biggest problem as doctors is what causes such ‘normal’ miscarriages and what we can do about them.

In actuality, the human fetus grows from a seed, and this human seed behaves generally like the seeds of all living things. The possibility of imperfect seeds is universal throughout the animal and plant kingdoms, and abortion is only another expression of the fact that the complicated processes of life and reproduction are always subject to misadventure.

Defective Germ Plasm

Many years ago I heard the late Dr. George Streeter, distinguished head of the Carnegie Institute of Embryology, discuss this topic before the learned members of the New York Obstetrical Society. He stood upon the rostrum, the eyes of the audience fixed upon him and, like a small boy with a pocket full of treasure, drew from his tuxedo vest two unopened pods of ordinary garden peas. ‘Gentlemen,’ he began, as he publicly shelled his peas, ‘I cannot be sure, but I’ll hazard the guess that these pods will contain one or two bad, runted peas—defective germ plasm conceptions.’ They did.

Try it yourself. I think you may then be inclined to regard abortion less as a freak abnormality and more as a common occurrence among all live things which develop from minute beginnings.

Actually, three out of four abortions are caused by faulty seeds, defective germ plasm. This means simply that things are not going properly, and the conception ceases to develop; after days or weeks it is expelled normally. Medically speaking, such an abortion is a fortunate occurrence, although the woman who does not understand this is upset by her supposed misfortune.

If the conception is expelled because it is not progressing normally, either the embryo is nonexistent or defective, or else the placenta is deficient and so cannot supply adequate nutrition for the fetus. Often both embryo and placenta are abnormal.

Theoretical Causes of Defective Germ Plasm

We do not really know what causes a defective conception, except that nature is not always benevolent and kind. But we assume the cause to lie in one of four places: the sperm, the egg, the process of fertilization, or the implantation of the fertilized egg. 1. The fertilizing sperm may have been a dud and may have transmitted, instead of the father’s apparent health and vigor, some hidden lethal factor. In this case the baby, if it had developed, would not have been normal anyway, and nature has provided abortion as a means of avoiding this consequence. Women who have been terribly disturbed by an involuntary abortion may be comforted to know that by this they have perhaps been spared a more serious misfortune. 2. The same may be true of the egg. Not all eggs are good eggs, or are potentially capable of developing into healthy babies. 3. The sperm and the egg may both have been normal and healthy, but their union may have been faulty. Fertilization is a very complicated physical-chemical process, and does not always occur successfully, even though the two bits of germ plasm involved are healthy. 4. The sperm and the egg may be healthy and the fertilization normal, but the conceptus (the fertilized egg) may not have found a suitable environment in which to grow. That is, the fertilized egg may somehow not be implanted properly in the uterus, where it has to live and grow for nine months. Sometimes if it is planted in the wrong place, especially in the lowermost portion of the uterus, frequent bleeding will occur during early pregnancy and abortion will follow. A bulb or seed will not flourish if planted too deep or too superficially, or in improper soil. We believe that the human egg behaves similarly.

The Reaction of the Uterus to Defective Germ Plasm

A fetus that is not developing properly will die, and then it is like foreign material in the uterus. The normal reaction of the body is to expel foreign matter. We try to cough up a small bone in the throat, or blink a cinder from the eye. Similarly, the muscular contractions of the uterus force out the dead conceptus, which, through its death, has become foreign to living tissue, the uterus.

The defective germ plasm conceptus stops developing and dies six or seven weeks after the pregnancy begins, that is, after the last period, but four or five weeks after actual fertilization, and remains in the uterus for another three or four weeks before being expelled. Thus the actual process of abortion occurs at about the tenth or eleventh week.

Late Abortions

Ordinarily abortions caused by maternal disease or some abnormality of the uterus or cervix occur between the thirteenth and twenty-eighth weeks. Abortions occurring during this period are very likely to result in a well-formed fetus which is either living or has very recently died.

Superstitions about Abortion

There is a firmly ingrained belief that abortion is likely to occur at the precise time a missed menstrual period is due and, therefore, many women take unusual precautions during the eighth week and again during the twelfth week. Since statistically most abortions take place during the tenth and eleventh weeks, it is easy to upset this superstition and to assure the reader that such time-localized restrictions are quite unnecessary.

Undoubtedly many physicians of yesteryear, as mystified about the cause of a miscarriage as the patient, eagerly accepted her pat explanations. A woman of ancient Greece was frightened by a clap of thunder (to be sure it was not the first time Attic thunder had frightened her during the pregnancy) , and she miscarried two days later. A Roman matron was riding in her chariot when it hit a rut in the street which the Roman city fathers had neglected to repair. And three days thereafter she aborted. The circumstances were reported to the respective physicians, who duly noted them in their clinical notebooks. When later these doctors became authors of medical treatises they constructed their theories for the cause of abortion from the cases they had earlier recorded. When later authors also wrote books, they added to their own guesses those copied from the authorities who preceded them. And the ‘causes’ of miscarriage multiplied almost as rapidly as the human race. Even today one of the most difficult tasks in medicine is the separation of happenstance from cause.

How to Prevent Abortion

I forbid neither travel, horseback riding, nor any activity to the normal woman in early or late pregnancy. My leniency is based on the premise that you cannot shake a good human egg loose any more than you can shake a good unripe apple from the apple tree. If you could, there would be no work for illegal abortionists, nor would the strong wind out of the north leave any fruit to ripen in the orchard. Nature sometimes makes mistakes, but she fanatically preserves her seed and the fruits therefrom which are normal and not mistakes.

What a particular doctor prescribes when a woman bleeds vaginally in early pregnancy depends on two highly variable and equally important factors—the doctor and the patient. And since by no stretch of the imagination am I either your, the reader’s, physician, or a paper substitute for him, the first thing to do is to report the bleeding to your doctor and ask him for instructions.

The usual treatment is bed-rest combined with the administration of various gland or hormone preparations. When I adopt this form of therapy—and occasionally I do—it is because the patient expects it and would consider herself neglected if I did not prescribe it.

Since early miscarriages are usually caused by defective germ plasm, by the time bleeding occurs the conceptus has already been dead a week or two, and no medication can restore life to dead matter. On the other hand, if the bleeding is very light and passing, then it is probably caused by some small complication that will not result in abortion. If so, the bleeding is harmless and will disappear by itself or perhaps after simple treatment of the cervix.

If my patient is calm and understanding, I explain these matters to her when the bleeding starts. If after the explanation and my confession that miscarriage is a field of relative uncertainty and ignorance, she elects the usual orthodox hormone treatment, I prescribe it—no miracles promised. Many patients choose to continue their activities and are happier and less anxious when they do.

If the bleeding occurs after the twelfth week, when it is more likely that the conceptus is normal and some unknown, perhaps medical or mechanical, factor is responsible, bedrest and medicines make more sense. I use them routinely at this period—that is, if examination shows the uterus to be developing normally in size and not far smaller than it should be, which would indicate the retention of a dead conceptus.

Time after Abortion before Another Pregnancy

How long should a woman wait after aborting before she tries to become pregnant again? If defective germ plasm is proved responsible, then attempts to start another pregnancy should be begun immediately after the first menstrual period, which usually comes about four weeks to the day after the abortion. It is only a question of combining a good sperm with a good egg; the more often you try, the better your chance of hitting the right combination. In such cases, provided the patient is not already producing too much thyroid, as first determined by routine thyroid tests, I prescribe thyroid tablets to be taken while attempting conception and to be continued after conception has occurred.

If the abortion was definitely not caused by defective germ plasm, and a complete physical examination, including a hysterogram (X-ray of the cavity of the uterus), does not reveal what caused it, then I usually advise a waiting period of about six months. Something caused pregnancy to terminate very prematurely and, since I cannot find out what it was and correct it, I propose to wait and hope that it will correct itself. Then, when such a patient conceives, I may give her progesterone, a gland preparation, to reinforce the chemical output of the early placenta.

The Repetition of Abortion

What are your chances of a successful pregnancy if you have aborted once before, or twice, or three times? If it was only once, you have practically as good a chance as any woman who has never aborted—even without any treatment. If you have aborted twice in succession, your chances without treatment are somewhat reduced, perhaps to three in five. And if you have had three successive abortions, then the chances of your bearing a child without medical aid are perhaps less than fifty-fifty.

In other words, if you have aborted once, you do not have too much to worry about when you try the second time. If you have aborted two or more successive times, then you had better go to an especially well-qualified doctor and follow his advice carefully.

Your chances of producing a living child if you are a chronic aborter—that is, have had three or more successive miscarriages—have been considerably improved by modern medicine. One obstetrician reports that dietary instructions plus thyroid treatment have helped 80 per cent of his chronic aborters to carry their pregnancies successfully. Other authorities use the two hormones stilbestrol and progesterone. Yet others have achieved miracles with psychotherapy plus liberal amounts of vitamins B and C. This multiplicity of successful therapeutic agents is confusing. It seems to boil down to the fact that there is a strong psychic component in repetitive abortion, and if the patient is sufficiently reassured by the authoritative attitude of her specially qualified physician, the psychic component is largely eliminated. This, plus meticu- lous care by the specialist who makes the problem of repetitive abortion his primary interest, probably explains the good results from so many different methods of treatment.

The Story of a Typical Abortion

It is somewhat hazardous to enumerate medical signs and symptoms for the benefit of lay readers. They immediately search for them in their own cases, and if the signs are present or absent they are prone to misinterpret their observations. Therefore, I should like to caution against self-diagnosis in this situation.

In a typical abortion the couple has required a few months more than the usual two or three months to conceive. The woman is free of all pregnancy symptoms except the missed menses. The absence of any nausea is striking. She goes to her doctor’s office when two months ‘pregnant,’ and says to him, ‘I feel swell; if it were not that I missed, I wouldn’t know I was pregnant.’ On pelvic examination the doctor makes a mental note that the uterus feels slightly firmer and smaller than it should for nine weeks’ duration, but since many normal pregnancies at first give the same impression, he holds his peace. Ten weeks after the onset of the last menses the girl notices a brownish stain on the toilet tissue after voiding. On more careful inspection, the stain is found to come from the vagina, but there is no pain. Her breasts either never expanded, or if they did, have gone down in size. The stain appears and disappears; it is a kind of dirty smudge mixed with mucus. Sometimes it is brown-red in color. During the night the staining stops, but on first getting up it is particularly noticeable. This simply means that the small amount of blood lost during the night is retained as a pool in the vagina and, when she assumes an upright position, it drains out. In a few days there is a dull ache in the lower abdomen, and the brown bleeding is now bright red. Some hours later cramps like exaggerated menstrual cramps appear. She begins to bleed more freely, the blood is a brighter red in color, and there is the passage of a few egg-sized clots. When the cramps have reached a crescendo she passes a peach-sized clot which is firmer and shaggier than the others. The cramps suddenly cease; the bleeding slows to a trickle and soon becomes just a stain. This is the story of a complete abortion.

On examination of the peach-sized mass, the doctor discovers that it is the whole egg sac, which may contain a badly degenerated fetus or no fetus at all. In either instance the process is all over and no curettage is necessary.

An Incomplete Abortion

In perhaps half the cases there is continuation of bleeding with clot formation, despite the passage of some firmer tissue. This indicates that some placental tissue still remains. Under such circumstances the abortion is usually completed after hospitalization by either hypodermic injections of the drug Pitocin, causing the uterus to contract, which may squeeze out the placental fragments, or by a simple operation. In the jargon of the medical profession, the operation is termed a ‘D and C,’ the letters standing for dilatation and curettage. The patient is first anesthetized; then, through the vaginal route, the cervix is dilated or stretched with a series of graduated metal dilators until sufficiently open to admit a small rakelike instrument, a curette. The cavity of the uterus is then raked clean of its remnants of afterbirth.

The Danger from Abortion

Today women do not die from spontaneous abortion. Danger from severe blood loss, a rare occurrence, is neutralized by adequate transfusions and the menace of infection by powerful, readily available antibiotics.

The danger of despair, the feeling of frustration, is less easy to control. But remember, abortion is an unfortunate failing on nature’s part, not yours. And if you are philosophical and courageous enough to try again, it is more than likely that with your doctor’s help you will be successful.

Induced Abortion

The term ‘induced abortion’ includes all pre-viable terminations of pregnancy initiated by artificial means, in contrast to spontaneous abortions, which initiate themselves. One might differentiate them by saying that the former is man-made; the latter, God-made.

There are two kinds of induced abortions, therapeutic and illegal. The difference between them was succinctly brought out at a student recitation thirty-five years ago in one of the third-year classes of the Johns Hopkins Medical School.

The professor, the late eminent J. W. Williams, asked a Mr. Meyers, ‘What is the difference between therapeutic and illegal abortion?’

Meyers hesitated and then ponderously declaimed, ‘Sir, a therapeutic abortion is done to save the fife of the mother.’

And in a flash the professor said, ‘Yes, and an illegal abortion to save the life of the father.’

Therapeutic Abortion

Each of the fifty states has a specific statute regulating abortion. The majority of the state laws declare that pregnancy may be terminated before a baby is viable only if deemed medically essential ‘to preserve the life of the mother’; the minority are phrased ‘to preserve the life or health of the mother.’ The machinery for rendering such an important medical decision is spelled out by some of the statutes. Ordinarily two physicians in good standing must affirm in writing the necessity for the procedure.

Since today all therapeutic abortions are performed in hospitals, many hospitals have additional regulations which are binding on its staff. As therapeutic abortion is never allowed on any grounds by the Roman Catholic religion, no Catholic hospital will permit its performance within its walls. Non-Catholic hospitals have various regulations; in some the only requirement is the hospital superintendent’s validation, while in others, such as the Mount Sinai Hospital in New York, there is a staff committee which must first give its sanction. The incidence of therapeutic abortion varies markedly from institution to institution, depending in part on local medical attitudes, and in part on whether or not the hospital is outstanding and the special repository of medical problem cases. As a result of the constant improvements in medical diagnosis and treatment, the necessity of performing therapeutic abortion becomes less and less frequent each year. For example, tuberculosis, which presented the most common indication for interruption of pregnancy, can now be cured by specific drug treatment during pregnancy, and pregnancy is allowed to continue.

Some of the commoner conditions which may require therapeutic abortion are psychotic states, where there is danger of suicide; previous, surgically proved malignancy, particularly of the breast or generative organs; desperately severe heart disease; chronic high blood pressure with kidney involvement; some rare illnesses; and the occasional conception which carries with it extreme likelihood of a grave congenital defect in the newborn. To be sure, therapeutic abortion for such eugenic reasons is not given sanction by the precise legal verbiage of most state statutes. Nevertheless, many doctors with good conscience interpret ‘preservation of the life of the mother’ not to mean just pure survival, but the preservation of her emotional life as well. Some physicians feel that the necessity to rear a tragically handicapped child places in serious jeopardy the emotional life of parents.

When a woman is less than twelve weeks pregnant therapeutic abortion is usually performed vaginally. The procedure—uterine curettage, preceded by dilatation of the cervix —is relatively simple, and recuperation requires only a few days.

If the woman is more than twelve weeks pregnant, the conceptus is usually too large to permit emptying the uterus with ease and safety vaginally, so that a small abdominal incision becomes necessary. The uterus is then incised and evacuated; the operation is virtually a miniature Cesarean section. As long as the abdomen is open, if the condition which necessitated interruption of pregnancy is destined never to improve sufficiently to render pregnancy safe, sterilization is carried out at the same time. The sterilization part is simple and quick; each Fallopian tube or oviduct is tied and severed. By interrupting the pathway, a permanent roadblock is created, so that the egg can no longer descend to meet the sperm, nor can the sperm ascend to meet the egg. Such a sterilization technique removes no tissue; neither ovulation, menstruation, nor the production of hormones is altered. Therefore there is no possible effect on body weight or sexual functions, except that coitus can be practiced without chance of pregnancy. A new method of aborting a pregnancy beyond twelve weeks has been introduced via Sweden. A long injection type of needle is introduced through the abdominal wall just below the navel into the uterus. About a half-pint of amniotic fluid is withdrawn and an equal amount of a strong salt (20 per cent) or glucose (50 per cent) solution is injected through the same needle. The needle is then withdrawn. In my experience contractions of the uterus commence within twenty-four hours, and in six hours or less the patient miscarries spontaneously.

Illegal A bortion

Illegal abortion is a widespread social and medical disease. It carries danger to life, health, and morals. Because it is illegal and clandestine, it is closely intertwined with rackets and all manner of antisocial practices.

The attitude of society toward illegal abortion is now largely one of indifference and pretending that the evil does not exist. Some day men will accept their responsibility and face the problem head on. Then medicine, sociology, the law, government, and religion will sit down together and discuss illegal abortion in realistic terms and not in insincere plat- itudes. Then and only then can a remedial program be evolved.