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TREATMENT OF HABITUAL ABORTION

D. C. A. BEVIS

M.B. Mane., M.R.C.O.G.SENIOR REGISTRAR, ST. MARY’S HOSPITALS, MANCHESTER

SINCE 1948 a special clinic has been held in St. Mary’sHospitals, Manchester, for the investigation and treatmentof habitual abortion.This account deals only with patients, seen at this

clinic, who had had abortions in three or more consecutivepregnancies. Patients were referred from the antenatalclinic of the hospital at their first attendance, usuallybetween the 8th and 12th week of pregnancy. Whenthey first attended the special clinic a full clinicalexamination was made, including pelvic examination toexclude abnormality of the uterus. As soon as possibleafter this the following tests were performed : (1) glucosetolerance, (2) basal metabolic rate, and (3) blood-chol-esterol. The patient was seen again at fortnightly inter-’vals. On each occasion the pregnanediol excretion wasdetermined on a 24-hour specimen of urine. Treatmentwas limited to an attempt to correct persistent abnor-malities shown by any of these tests. No routine treat-ment was applied other than advising rest at the timewhen the menses would have been due.

After the 28th week of pregnancy patients were referredback to their original clinic for further antenatal careand for delivery.

RESULTS .

Of 32 patients who had had 3 or more abortions, 29reached the 28th week -of pregnancy ; and 26 of thebabies were born alive and well. Details of the resultsare given in tables I and 11.From the results of the investigations some facts emerge

concerning the aetiology of the abortions.Anatomical Causes.-2 cases of retroversion of the

uterus were discovered in this series, and an additionalpatient was considered to have an infantile uterus whenseen shortly before the latest pregnancy. None of these

patients received treatment, and all gave birth to livingchildren at full term. In no case was there evidence -of

incomplete development of the internal cervical os, as

described by Lash and Lash (1950) ; and no evidence ofintra-uterine adhesions was discovered. None of the

patients appeared to have any degree of double uterus.Hormonal Causes.-2 patients had impaired thyroid

function, as judged by the basal metabolic rate and theblood-cholesterol level. 1 patient had had 6 previousabortions, and the other 5 abortions ; both patients weregiven thyroid gr. 1/2 (30 mg.) twice daily until the 28th

TABLE I-PRIMARY ABORTIONS

3 children were stillborn, the causes being: (1) pre-eclampsiaand difficult forceps extraction; (2) prolapsed cord ; and (3)abnormal foetus.

In the test of significance, only primary abortions are consideredsince there are too few secondary abortions for analysis, x2 (Yates’scorrection)=1222 ; P <-005. There is a marked difference betweenthe series and the spontaneous-cure rate.

week of pregnancy, and were eventually delivered of

living children at term8 patients had persistently low pregnanediol excretions,

judged by the normal values given by Hain (1942).Ethisterone 10 mg. daily was given in one of the earlycases ; and although the pregnanediol excretion did notrise the patient was delivered of a living child at term.The effect on the pregnanediol excretion of progesterone5 mg. twice or three times a week was variable, but allthe 9 patients thus treated were delivered at term. Theadministration of oestrogens with the progesterone didnot appear to affect the pregnanediol excretion.No impairment of glucose tolerance was noticed in any

patient.Rhesus Incompatibility.-All the patients were Rh-

positive except 1 ; and in this there was no evidenceof sensitisation.

Abitormality of the Fcets.-1 patient, delivered atterm gave birth to a grossly abnormal foetus ; but noevidence of abnormality could be found in any of the otherbabies, and examination of the 3 aborted foetuses did notreveal any gross abnormality.

DISCUSSION

Treatment was purposely kept to a minimum, and, asalready stated, was aimed at correcting persistentlyabnormal results in the various tests employed ; as a

result, at least 2 weeks elapsed before treatment couldbe undertaken, and in many cases it was 4 weeks beforethe abnormality could be adequately treated. Despitethis, 26 out of 32 patients gave birth to living babies.The spontaneous-cure rate in habitual abortion varies,

according to whether the abortions are primary or

secondary. Malpas (1938) stated that the cure-ratevaries between 7% and 27% for 3 previous abortions,while Jaevert and others (1949) gave the rate as 26%for primary abortions and 43% for secondary abortions.Taking all the present series as having had 3 previousabortions, thus erring on the side of severity in tests ofsignificance (a tendency further emphasised by basingthe results on live births only), the results show a signi-ficant difference from the spontaneous-cure rate. It is

apparent, therefore, that good results can be obtainedwith the minimum of treatment, and routine administra-tion of progesterone and other hormones has little tocommend it.

In the present series there was, admittedly, the benefitof extensive laboratory facilities ; but from the resultsit appears that if all the treated patients had abortedthe results would still have been better than the spon-taneous-cure rate. The most striking thing about thepatients attending the clinic was the confidence that theyhad in the investigations undertaken, and this probablyplayed a large part in producing the results obtained.Probably such psychological benefit, involuntarily given,is the best treatment that they can receive ; and the onlyother treatment the patient needs is rest over the timewhen the menses are due.

SUMMARY

Of 32 patients with 3 or more previous abortions, 26gave birth to live children.The best form of treatment in such cases is to instil

confidence in the patient, and to get her to rest over thetime when her periods would have been due.Thanks are due to the honorary staff of the hospital for

referring the cases to the special clinic, to my predecessors inthe clinic, to the director of the clinical laboratory of Man-chester Royal Infirmary for the laboratory investigations,and to Dr. A. M. Hain for the pregnanediol estimations.

REFERENCES

Hain, A. M. (1942) J. Endocrinol. 3, 10.Jaevert, C. T., Finn, W. F., Stander, H. J. (1949) Amer. J. Obstet.

Gynec. 57, 878.Lash, A. F., Lash, S. R. (1950) Ibid, 59, 68.Malpas, P. (1938) J. Obstet. Gyn&oelig;c. 45, 932.