Current Trends Deaths Attributable to Tubal Sterilization -- United States, 1977-1981

From 1977 through 1981, 29 deaths attributable to tubal sterilization were reported in the United States. Eleven of these followed complications of general anesthesia; seven were due to sepsis; four, to hemorrhage; four, to cardiovascular events; and three, to other causes.

Over five million women underwent tubal sterilization during the 1970s, with an estimated case/fatality rate of 3.6/100,000 (1). In 1979, CDC began surveillance of tubal sterilization deaths to determine why they occur and what can be done to prevent them. Sterilization-attributable deaths were identified through a nationwide reporting effort involving individual clinicians, state health departments, medical examiners' offices, and professional societies 1970s, with an estimated case/fatality rate of 3.6/100,000 (1). In 1979, CDC began surveillance of tubal sterilization deaths to determine why they occur and what can be done to prevent them. Sterilization-attributable deaths were identified through a nationwide reporting effort involving individual clinicians, state health departments, medical examiners' offices, and professional societies and through the Commission on Professional and Hospital Activities (CPHA). CPHA annually collects information on approximately 40% of patients discharged from U.S. short-stay hospitals (2). Medical records were requested for each death, and a detailed clinical summary was prepared without any identifying information. A death was considered sterilization-attributable if it would not have occurred in the absence of the tubal sterilization.

Hypoventilation was believed to have contributed to six of the 11 deaths attributed to general anesthesia complications. No woman whose death was so attributed had been intubated. Of four women who died after intraoperative cardiac arrests of unknown causes, three had conditions that may have contributed to death. The remaining death resulted from an idiosyncratic reaction to anesthesia.

Of the four women who died of cardiovascular complications, three died of postoperative myocardial infarction; they were ages 33, 35, and 37, and none had a preoperative diagnosis of cardiac disease. The fourth woman, aged 24, who took oral contraceptives up to the day of tubal sterilization died of a mesenteric vein thrombosis.

Three of the seven women whose deaths were attributed to sepsis had apparent bowel injury following unipolar coagulation. Of the four remaining deaths, three followed other types of organ injury, and the fourth followed a pelvic infection of unknown origin. Three of the four deaths attributed to hemorrhage followed major vessel lacerations that occurred on entry into the peritoneal cavity during a laparoscopic sterilization; the remaining death occurred after a surgical ligature slipped from a fallopian tube stump. Reported by Epidemiologic Studies Br, Family Planning Evaluation Div, Center for Health Promotion and Education, CDC.

Editorial Note

Editorial Note: The 29 reported deaths do not represent all the sterilization-attributable deaths from 1977 to 1981; as many as 108 such deaths may have occurred (3). If this estimate is correct, surveillance has identified 27% of the estimated sterilization-attributable deaths.

In 1981, CDC reported that anesthesia complications were the leading cause of abortion-related deaths and that use of general anesthesia increased the risk of death associated with induced abortion (4). Similarly, the risk of death from tubal sterilization appears greater with general than with local anesthesia. Hypoventilation has been reported as a leading cause of anesthesia-related deaths for a variety of surgical procedures (4,5) and also appears to be a major cause of anesthesia-related tubal sterilization deaths. No women whose deaths were attributed to hypoventilation had been intubated before sterilization; furthermore, four of these six women had laparoscopic tubal sterilizations. Endotracheal intubation--particularly for laparoscopic sterilization--has been recommended in an attempt to prevent hypoventilation deaths (6).

Four women died from cardiovascular complications following sterilization procedures. Among factors that may have increased their mortality risk were: smoking, oral contraceptive use at the time of surgery, and age over 35.

Three deaths due to sepsis were attributed to thermal bowel injury associated with unipolar coagulating devices. Because unipolar coagulation may be associated with greater risk of electrical accidents than bipolar coagulation, without any demonstrated greater efficacy, its continued use in tubal sterilization has been questioned (7). Recently, the Board of Trustees of the American Association of Gynecologic Laparoscopists issued a statement suggesting that procedures other than unipolar coagulation be encouraged for laparoscopic sterilization (8).

CDC continues its surveillance of sterilization-attributable deaths and requests that information about individual cases be reported to: Sterilization Surveillance Activity, Epidemiologic Studies Branch, Division of Reproductive Health, CDC.

References

1. Peterson HB, DeStefano F, Greenspan JR, Ory HW. Mortality risk associated with tubal sterilization in United States hospitals. Am J Obstet Gynecol 1982;143:125-9.

2. Jick H. The Commission on Professional and Hospital Activities--Professional Activity Study. A national resource for the study of rare illnesses. Am J Epidemiol 1979;109:625-7.

3. Peterson HB, DeStefano F, Rubin GL, Greenspan JR, Lee NC, Ory HW. Deaths attributable to tubal sterilization in the U.S., 1977-1981. Am J Obstet Gynecol 1983;146:131-5.

4. Peterson HB, Grimes DA, Cates W, Jr, Rubin GL. Comparative risk of death from induced abortion at less than or equal to 12 weeks' gestation performed with local versus general anesthesia. Am J Obstet Gynecol 1981;141:763-8.

5. Taylor G, Larson CP, Jr, Prestwich R. Unexpected cardiac arrest during anesthesia and surgery. An environmental study. JAMA 1976;236:2758-60.

6. Fishburne JI. Anesthesia for outpatient female sterilization. Biomedical Bulletin: Association for Voluntary Sterilization, Inc. 1983;4:1-6.

7. Peterson HB, Ory HW, Greenspan JR, Tyler CW, Jr. Deaths associated with laparoscopic sterilization by unipolar electrocoagulating devices, 1978 and 1979. Am J Obstet Gynecol 1981;139:141-3.

8. Board of Trustees, American Association of Gynecologic Laparoscopists. Unpublished communication to members.

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