Epidemiologic Notes and Reports Maternal Deaths Associated with Barbiturate Anesthetics -- New York City

While reviewing pregnancy-related deaths in New York City since 1980, the New York City Bureau of Maternity Services and Family Planning noted that seven deaths were associated with the administration of an ultrashort-acting barbiturate anesthetic (Brevital) for termination of pregnancy. All seven women suffered cardiorespiratory arrest either during induction or shortly thereafter on the operating room table or in the recovery room.

All seven women were black. Five were 21 years of age or younger. The mean gestational length was 13 weeks; cases included both first- and second-trimester termination procedures. Two procedures were performed in hospitals, four in free-standing clinics, and one in a private physician's office. The dose recommended for methohexital sodium (Brevital) is 1.5 mg/kg body weight, with an induction dose of 75-100 mg administered intravenously (IV) (1). The mean dose for six of the seven women reviewed was 2.4 mg/kg, with a range of 1.0 mg/kg to 4.5 mg/kg (Table 1).

An expert advisory panel, convened by the New York City Department of Health (NYCDH), reviewed charts, termination-of-pregnancy certificates, and autopsy reports. The panel concluded that these deaths were related to complications of anesthesia and that black women under 25 were overrepresented among the decedents, since they comprised only 26% of all women obtaining abortions in New York City during the same period (2). New York City's Commissioner of Health issued an alert (3) to physicians and administrators stipulating that standards set by the Joint Committee on the Accreditation of Hospitals (JCAH) (4), the American College of Obstetricians and Gynecologists (5), and the NYCDH (6) be met whenever general anesthesia is administered.

Because of concern by the NYCDH, abortion mortality data collected by CDC were reviewed to further describe the epidemiology of abortion risks in New York City compared with the United States as a whole. CDC has identified and investigated 193 legal-abortion-related deaths that occurred in the period 1972 through March 1985.

The overall abortion-related mortality rate in New York City between 1972 and 1981 was higher (though not statistically significantly) than in the other parts of the country for white women, for women of black and other races, and for women of all races combined. Mortality rates for 1982-1985 are not included because the total numbers of abortions for those years are not yet known.

Of the 193 legal-abortion-related deaths, 27 (14%) were attributed to complications of general anesthesia. The proportion of legal-abortion-related deaths attributed to complications of general anesthesia was significantly higher in New York City than in the remainder of the United States. This finding persisted throughout the period 1972-1985 (Table 2). Comparisons of women dying from complications of general anesthesia with women dying from other causes in New York City and in other places found the following: in New York City, both groups had similar distributions by age, race, marital status, and gravidity; in places other than New York City, a significantly higher proportion of blacks were among women dying from complications of general anesthesia; and in both comparisons, a significantly higher proportion of women dying from complications of general anesthesia died during the first trimester.

Regarding type of anesthetic, CDC data reveal that, among the 27 women whose deaths were attributed to complications of general anesthesia, the type of anesthetic used was known only in 23 cases. In 21 cases, short-acting barbiturates were used (Brevital in 16, Pentothal in three, Surital in one, and unspecified barbiturates in one). The dose employed was stated in only four cases (in addition to the above seven cases reported from New York City), but the women's weights were not stated.

Thus, a large percentage of deaths due to complications of general anesthesia was associated with the use of short-acting barbiturates. However, based on available information, a drug-specific mortality rate could not be estimated, nor could a general-anesthetic-specific mortality rate be calculated. Reported by W Chavkin, MD, L Fernandez, M Harris, MD, GK Higginson, MD, J Pakter, MD, New York City Dept of Health; Pregnancy Epidemiology Br, Div of Reproductive Health, Center for Health Promotion and Education, CDC.

Editorial Note

Editorial Note: The higher overall legal-abortion-related mortality rate in New York City as compared with that in other parts of the United States between 1972 and 1981 may be due to the fact that women obtaining abortions in New York City during that period were in a higher risk group than women obtaining abortions in other parts of the United States. CDC abortion surveillance data show that, compared with women obtaining abortions in other parts of the United States, the New York City women were generally older, a higher proportion were of black and other races, and a higher proportion obtained their abortions during the second trimester. The significantly increased proportion of abortion-related deaths associated with general-anesthesia complications in New York City may be partially explained by the more frequent use of general anesthetics for performance of abortions in New York City than in the other parts of the country (7).

Previous studies have shown that, compared with local anesthetics, the use of general anesthesia for induced abortion during the first trimester was associated with a twofold to fourfold increased risk of death (8). However, general anesthetics have been frequently used when abortions are performed. It is estimated that general anesthetics were used for approximately 46% of all abortions done in hospitals during 1971-1975 (9) and approximately 27% of all abortions done in clinics during 1976-1977 (10).

The fact that most deaths due to general anesthesia occurred during the first trimester may be expected, since more than 85% of all abortions done in the United States between 1972 and 1981 were done during the first trimester (11) and since general anesthesia is more commonly employed during first-trimester procedures than second-trimester procedures. Data from the Joint Program for the Study of Abortion reveal that, between 1975 and 1978, 26% of first-trimester abortions were done under general anesthesia, compared with 13.6% of those done during the second trimester (12).

Short-acting barbiturates have an important place in the practice of anesthesiology. They are the IV anesthetics of choice for most anesthesiologists. They are used to induce general anesthesia and are commonly used for maintenance during procedures lasting 15-20 minutes (11). However, the frequency of using short-acting barbiturates for pregnancy termination procedures is not known.

The deaths due to complications of general anesthesia underscore the need for close and continuous supervision of general-anesthesia administration by a qualified anesthesiologist, adequate recovery-room monitoring, and particular care in dose calculation using patient weight. Investigation of seven general anesthetic-related deaths by the New York City Bureau of Maternity Services and Family Planning revealed that four of six women were given overdoses of methohexital. Data to compare adverse reactions associated with the use of methohexital for other procedures are not available. The above analysis demonstrates an increase in the contribution of general-anesthesia complications to abortion-related deaths. While the overall abortion mortality rate based on deaths reported to CDC declined by 87% from 1972 to 1981 (11), the proportion of abortion-related deaths due to complications of general anesthesia increased from 11% between 1972 and 1979 to 29% between 1980 and 1985 (Table 2). Most of those deaths (24 of 27 (89%)) occurred during the first trimester. The increased risk of using a general anesthetic rather than a local anesthetic for first-trimester abortion has been documented (8). Clinicians should carefully review their use of general anesthetics for pregnancy-termination procedures, especially during the first trimester.

References

1. Gilman AG, Goodman LS, Gilman A. Goodman and Gilman's: the pharmacological basis of therapeutics. 6th ed. New York: MacMillan Publishing Co., 1980.

2. New York City Department of Health. Unpublished data based on analysis of Termination of Pregnancy Certificates.

3. New York City Commissioner of Health. Alert to all obstetricians, gynecologists, anesthesiologists, directors of free-standing Ob/Gyn clinics and hospital administrators (Letter). 1985 (May 13).

4. Joint Commission on the Accreditation of Hospitals. Hospital accreditation manual. Chicago, Illinois: Joint Commission on the Accreditation of Hospitals, 1985.

5. American College of Obstetricians and Gynecologists. Standards for obstetric-gynecologic services, 5th ed. Washington, D.C.: American College of Obstetricians and Gynecologists, 1982.

6. New York City Department of Health. Guidelines for out-of-hospital late abortions ("second trimester abortions"). New York City Department of Health, 1985.

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