An unusual complication of unsafe abortion.

UNLABELLED: Unsafe abortion is a significant medical and social problem worldwide. In developing countries, most of the unsafe abortions are performed by untrained personnel leading to high mortality and morbidity CASE REPORT: A 30 year-old female, gravida 7, para 6 underwent uterine evacuation for heavy bleeding per vaginum following intake of abortifacient to abort a 14 weeks gestation. The procedure was performed at a rural setup and her bowel was pulled out of the introitus through the perforated wound, an unusual complication of unsafe abortion. Illiteracy, unawareness about health services, and easy accessibility to untrained abortion providers lead to very high mortality and morbidity in India. There is unmet need to bring awareness among the people about the safe and effective methods of contraception and abortion services to avoid such complications.

INTRODUCTION

Unsafe abortion is a significant medical and social problem worldwide. According to World Health Organization, a woman dies every eighth minute in developing nation due to complications arising from unsafe abortion.[1] Each year 42 million abortions are estimated to take place, 22 million safely and 20 million unsafely. Unsafe abortion accounts for 70,000 maternal deaths each year and causes a further 5 million women to suffer temporary or permanent disability.[2] Approximately 1 in 10 pregnancies end in unsafe abortion, giving a ratio of 1 unsafe abortion to about 7 live births.[3] Most of the unsafe abortions are performed in developing countries. In western nations, only 3% of abortions are unsafe, whereas in developing nations 5% are unsafe. Highest incidences of unsafe abortions take place in Latin America, Africa, and South East Asia.[1] A survey of 2400 women in Madhya Pradesh, India, found that 32% of women aged 35–39 years had attempted abortion at some time, and 23% had an abortion, indicating that roughly one in four women who attempted abortion did not succeed. Self induced morbidity was higher in rural areas (57%) than in urban areas (45%). Severe complications were also more common in rural areas (35% versus 16%), showing that higher risks are associated with abortions in underserved rural areas. Not unexpectedly, only 9% of the women knew that abortion was legal, 49% thought that abortion was illegal, and 36% did not know its legal status; the remaining 6% reported knowing that abortion was legal, but their knowledge of the period within which it was legal was incorrect.[4] The main causes of mortality or morbidity due to unsafe abortion are hemorrhage, sepsis, genital trauma, and bowel injury. Here we are presenting a case report of an unusual complication of unsafe abortion where bowel is pulled out of the vaginal introitus through uterine perforation [Figure 1].

Figure 1

Congested and edematous intestinal loops pulled out of vaginal introitus

CASE REPORT

A 30 year-old female was admitted with complaints of pain abdomen and something coming out per vaginum since 2 hours following evacuation of the uterus done for an incomplete abortion following 3 months amenorrhoea. She was a gravida 7 para 6 and had taken an abortifacient 15 days before the day of admission to abort an unintended 14 weeks gestation. She had continuous bleeding per vaginum following that, for which she underwent uterine evacuation at a rural hospital. She developed acute pain abdomen and felt something at vaginal introitus following the procedure. She was brought to our hospital for further management. On examination, she was conscious but irritable and the pulse rate was 146/min, blood pressure 80/50 mm Hg, and temperature was 100°F. On abdominal examination, there was a vertical paramedian incision of previous caesarean section present. Abdomen was tense and tender. Bowel sounds were absent. On local examination, congested and edematous intestinal loops were seen outside the vaginal introitus. Per speculum and per vaginum examination was not possible because of the bowel loops obstructing the introitus tightly. Her investigations revealed hemoglobin 7.5 gm/dl, white blood cell count 28,690/-ml, platelet count 3,91,000/ml, blood sugar 100 mg/dl, and serum creatinine 0.9 mg/dl.

A clinical diagnosis of uterine perforation with shock was made, and her exploratory laparotomy was performed after resuscitation. Peroperatively, the perforation was present in the fundal region [Figure 2] of the uterus, and about 3 feet of small intestine was pulled out through it, which was gangrenous [Figure 3]. The mesenteric vessels supplying the segment were ligated and resected. The gangrenous intestinal segment was resected close to the perforation and an end to end jejunoileal anastomosis was done. The gangrenous intestinal segment was removed through the vagina and primary repair of the uterine perforation was done. Postoperatively she was kept on ventilator support for 2 days and three units of packed red blood cells, broad-spectrum antibiotics, and intravenous fluid were given. She responded well to the treatment and was discharged on the 14th postoperative day.

Figure 2

Laparotomy showing perforation in uterine fundus

Figure 3

Specimen showing resected gangrenous intestinal segment

DISCUSSION

The patient was multigravida and she wanted to terminate her unintended pregnancy for which she took some medicine herself. This results in incomplete abortion and she developed heavy bleeding per vaginum. She was brought to a rural setup nearby her village, where uterine evacuation was done which results not only perforation of the uterus but her intestine was also pulled through it out of the introitus leading to severe morbidity. In various studies, about 55–77% of abortions were carried out by untrained and unqualified people.[5-7] These unqualified abortion providers are easily accessible to the clients in countries such as India. Illiteracy, unawareness about the available health facilities, hesitations and myths about contraception use, over the counter availability of the drugs for medical abortion, and easy accessibility to untrained abortion providers lead to very high mortality and morbidity in India. Complication due to unsafe abortion accounts for an estimated 13% of maternal deaths worldwide or 70,000 deaths per year.[8] Although bowel perforation is a well-known complication of unsafe abortion, pulling of bowel upto the introitus is an unusual complication of unsafe abortion.

CONCLUSIONS

In spite of legalization of abortion in India in 1971, most of the abortions are done by untrained personnel. Factors inhibiting use of safe abortion where it is legal are lack of privacy and confidentiality, poor access, and discouraging attitudes of healthcare providers. Therefore, only legalization of abortion is not sufficient to reduce the number of unsafe abortions. There is unmet need to bring awareness among the people about the safe and effective methods of contraception and abortion services so that such types of complication can be prevented.