Association of Brain Damage with Therapeutic Abortion Induced by Amniotic-fluid Replacement: Report of Two Cases

Abstract

Recently amniotic-fluid replacement by the intrauterine injection of strongly hypertonic solutions has been used increasingly often to produce therapeutic abortions or to induce labour when the foetus is already known to be dead (Csapo, 1961;Wood, Booth, and Pinkerton, 1962). Few complications of the method have been reported, though it has been tried and discarded by other workers because of the risk of intrauterine sepsis (Peel, 1935). Two cases are reported in which widespread cerebral infarction occurred after the procedure and in which it was possible that the strongly hypertonic solutions employed were responsible for the brain damage. Case 1A previously healthy 20-year-old secretary was advised, on psychiatric grounds, to have a therapeutic abortion in the 20th week of her first pregnancy. The operation was performed under local anaesthesia by inserting a fine trocar and cannula through the anterior abdominal and uterine walls into the amniotic cavity, removing about 200 ml. of amniotic fluid, which was lightly bloodstained, and injecting manually approximately 400 ml. of sterile 20 ', sodium chloride solution. She appeared well immediately afterwards, but complained of a burning sensation in her finger-tips. After about four hours her condition deteriorated, and she began to have epileptiform fits. About 12 hours after the operation her blood-pressure was said to be normal. Sedatives were given parenterally as symptomatic treatment, but she suddenly stopped breathing and died some 22 hours after the intrauterine injections. A dead foetus had been delivered 12 hours after the intra-amniotic injection. Twelve hours after the amniocentesis serum electrolytes were: chlorides 143 mEq/l., sodium 174 mEq/l., potassium 3.7 mEq/l., urea 26 mg./100 ml.Necropsy showed evidence of the recent pregnancy. In the anterior wall of the fundus of the uterus there were two puncture wounds which appeared to have penetrated through the placental bed. The brain on removal appeared to be slightly oedematous, and no subdural or subarachnoid haemorrhages were seen. The lungs showed patchy collapse. The cardiovascular system seemed to be normal and there was no evidence of air embolism. There was no peritonitis, nor any excess of fluid or blood in the peritoneal cavity. The kidneys appeared normal. The foetus and placenta were not available for examination. Microscopical Examination of VisceraSections of heart, lungs, kidneys, liver, and spleen showed no histological abnormality. Pregnancy changes were seen in the pituitary, the breasts were active, and trophoblastic tissue was seen at the placental site in the uterus. Brain and Spinal CordAfter fixation the brain was cut in coronal slices. These showed symmetrical haemorrhagic softenings of both amygdaloid nuclei, sparing only a thin rim supero-medially, and similar softening of the adjacent parts of both the right and left uncus (Special Plate, Fig. 1). The inferior parts of both claustra and the adjacent insular cortex were haemorrhagic. Other parts of the cerebrum appeared nor...

Use of Prostaglandin E2 for Therapeutic Abortion

“…The former technique is usually employed after 14 weeks and, though usually successful, needs skill and experience. Recently, however, there have been disquieting reports of several deaths following the intraamniotic injections of hypertonic saline (Wagatsuma, 1965;Cameron and Dayan, 1966;Sabeti and de Watteville, 1967;Frost, 1968;Diggory et al, 1970). The abortifacient paste can be used in early and mid-pregnancy (Lachelin and Burgess, 1968), but is not free from risk, and sudden death from embolism or vagal inhibition has been reported (Dutra et al, 1950;Williams et al, 1955;Karim and Filshie, 1970).…”

Fatal outcome from administration of a salt emetic

“…Histological examination of the brain failed to show the frank neuronal necrosis reported by Cameron and Dayan (1966) and sections of Ammon's horn were normal. The only abnormalities apart from the recent haemorrhage were signs of early reactive changes in the astrocytes of the white matter.…”

“…Robertson (1971) mentioned the death of a 23-year-old woman consequent to the administration of a salt emetic after taking an overdose of chlordiazepoxide. Three patients dying after the intra-uterine injection of hypertonic saline as an abortifacient have been described (Cameron and Dayan, 1966;Dayan, Cameron and Phillipp, 1967 On discovery of her overdose a saline emetic was administered using six tumblerfuls of water each containing a dessertspoonful of salt. This is equivalent to 150 g sodium chloride or 2600 mEq sodium.…”

Amniotic fluid embolism and disseminated intravascular coagulation complicating hypertonic saline-induced abortion

“…Many complications of this technique have been reported: fever and infection (Gillmer, Friend and Beard, 1971;Goodlin et al, 1969;Mackenzie, Roufa and Tovell, 1971;Stim, 1972), haemorrhage (Stim, 1972), coagulation defects (Beller et al, 1972;Brown, Davidson and Phillips, 1972;Goodlin, 1971;Halbert et al, 1972), hypernatraemia (Cameron and Dayan, 1966;Droegemuller and Greer, 1970;Kerenyi, 1969), water intoxication (Abdul-Karim and Assali, 1961;Goodlin, 1971;Whalley and Pritchard, 1963), transplacental haemorrhage (Jorgenson, 1969;Parmely, Montague and Miller, 1970;Voigt and Britt, 1969), retained placenta (Frigoletto and Pokoly, 1971;Futoran, Lowenstein and Peacock, 1969;Kerenyi, 1971) uterine lacerations (Svane, 1960;Wood, Booth and Pinkerton, 1962), and maternal death (Cameron and Dayan, 1966;Goldman and Eckerling, 1972;Pathak, 1968). Amniotic fluid embolism (AFE) is a further possible complication.…”