Unsafe abortion: Addressing the anaesthetic confronts.

Unsafe abortion has a global incidence of about 20 million cases annually, out of which 97% cases are reported from developing nations. There are many reports showing the occurrence of bowel or uterine perforation in such instances, but most of them have concentrated upon surgical or obstetric complications. We report a case of unsafe abortion with ruptured uterus, intra-abdominal foetus, and bowel infarction that developed intraoperative cardiac arrest during the emergency laparotomy. This case highlights anaesthetic challenges in managing such critically ill-patients.

INTRODUCTION

Unsafe abortion is defined by the World Health Organization as a procedure for terminating an unwanted pregnancy, either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both.[1] Despite its higher incidence, unsafe abortion is one of the most neglected global health problem.[2] We report a case of unsafe abortion with ruptured uterus, intra-abdominal foetus, and bowel infarction that developed intraoperative cardiac arrest (ICA) during the emergency laparotomy.

CASE REPORT

A 22-year-old multiparous pregnant female (24 week gestation) was brought to the casualty in a state of altered consciousness, vomiting, and bleeding per vaginum (PV). She had a history of PV manipulation by a local health worker. On examination, she was pale, dehydrated, had tender and distended abdomen, blood pressure (BP) of 80/46 mm Hg, heart rate (HR) of 130/ min, respiratory rate of 35/min, and Glasgow coma score of 8. There was no neck rigidity and reflexes were normal. On PV examination, gangrenous bowel loops were found protruding out from the vagina [Figure 1]. Abdominal skiagram showed gas under the diaphragm, and electrocardiogram showed prolonged PR interval, wide QRS complex and peaked T wave.

Figure 1

Gangrenous bowel protruding out of vagina

She was rehydrated with normal saline (1 Litre intravenously [IV]) over 30 minutes. To manage hypoxia, invasive positive pressure ventilation (synchronized intermittent mandatory ventilation [SIMV]) was started, and Ryle's tube, Foley's catheterization and central venous cannulation were performed. Midazolam (0.02 mg/kg/hr) and Fentanyl (1 μg/kg/hr) infusion was started. Initial laboratory results revealed severe anaemia, deranged renal functions, metabolic acidosis, hyperkalaemia, and hyponatraemia [Table 1]. She was nebulised with Salbutamol (10 mg), and dextrose-insulin infusion started. Systemic examination and Laboratory investigations indicated unsafe abortion with uterine and bowel perforation. With continued fluid replacement (hydroxyl-ethyl starch [0.5 Litre], 1 unit of blood and normal saline [1 Litre]), her BP returned to 116/62 mm Hg within 2 hour of admission, and she was shifted for emergency laparotomy, under general anaesthesia [Table 1]. Immediately after opening abdomen, patient developed sudden hypotension and cardiac arrest, following a gush of fluid mixed blood clots and feculent matter expulsion. External cardiac massage was initiated, and one unit of colloid bolus and Inj. adrenaline (1 mg IV) were given as per advanced cardiovascular life support guidelines. Patient was successfully revived after 2 minutes, and Dopamine infusion (10 μg/kg/hr) started. Thereafter, her vitals remained stable with no further episodes of arrhythmia. Anaesthesia was maintained with Ketamine (10 μg/kg/min IV) and nitrous oxide-oxygen combination (60%/40%). Neuromuscular blockade was maintained by Atracurium (0.1 mg/kg IV bolus), as required throughout surgery. A 6-month-old dead foetus (head and thorax-abdomen in two separate pieces) was extracted from the peritoneal cavity [Figure 2]. Uterine perforation (3 cm × 4 cm) was present and bowel loops (ileum [1.5 feet], transverse and sigmoid colon) were gangrenous [Figure 3]. Resection anastomosis and subtotal hysterectomy was carried out, and ascending colon fashioned as end-colostomy. About one unit of blood and two Litres of fluid were transfused during the operative procedure. Surgery lasted for approximately four hour and thereafter, she was shifted to intensive care unit (ICU), and maintained in SIMV mode. Postoperatively, dopamine infusion was tapered over twenty-four hour, and the patient was successfully extubated after two days. The patient survived with no major organ failure or any neurological deficit, and discharged on the tenth post-operative day.

Table 1

Laboratory investigations

Figure 2

Mutilated foetus extracted from abdomen

Figure 3

Gangrenous bowel and perforated uterus after subtotal hysterectomy

DISCUSSION

Unsafe abortion accounts for 13% of worldwide maternal deaths, out of which majority of cases are reported from developing countries.[12] This is considered just the tip of the iceberg, as most cases are concealed because of legal implications. Uterine perforation, bleeding, injury to bladder or bowel, and septic shock are the immediate complications of unsafe abortion.[3] Most cases are due to unskilled instrumentation by the untrained local health workers. In this patient, PV manipulation by unskilled personnel perforated the gravid uterus, leading to migration of foetal parts intra-abdominally and herniation of bowel out of the vagina.

An integrated approach directed at rapid restoration of systemic oxygen delivery, and hemodynamic support by adequate fluid resuscitation and vasopressors has been shown to improve survival of such critically ill-patients. Keenan and Boyan showed that cardiac arrest was six times more likely to occur when anaesthesia was delivered under emergency settings.[4] However, infection control interventions (emergency laparotomy in this case) should also be implemented as soon as possible following successful initial resuscitation, as any delay significantly increases the mortality risk in such cases.[5] Therapy should also be guided by various parameters such as urine output, arterial blood gas analysis, and serum lactate levels that reflect the adequacy of systemic tissue perfusion and distribution.

In such a critical situation, limited time for evaluation, potential fluid-electrolyte-acid-base imbalance, and potentially “full stomach” situation further complicates the anaesthetic management. Apart from routine preparation, availability of adequate IV fluids, emergency drugs, defibrillator, and difficult airway cart should be ascertained. This condition necessitates emergency laparotomy under general anaesthesia because of potential risk of hypotension with regional techniques. Pre-oxygenation should be followed by rapid sequence induction (ketamine with suxamethonium) with Sellick's manoeuvre. Ketamine infusion may be a safer alternative for maintenance of anaesthesia in such hypotensive patients as inhalational agents may precipitate arrhythmias and cardiac arrest.[6] Common conditions associated with ICA include hypovolemic shock, acute electrolyte imbalance, transfusion reaction and hypoxemia.[7] Probable cause of ICA in this patient might be sudden loss of intra-abdominal pressure and consequent hypovolemic shock after abdominal incision. Previous data show that the most patients of hypovolemic shock recover with a minimal intervention if immediate resuscitation is initiated.[7] We observed a similar result in this patient by timely initiation of CPR after diagnosing ICA. The features of ICA are pulse less electrocardiography rhythm, loss of carotid pulse (>10 s), end-tidal CO2, plethysmograph and arterial blood pressure tracings. However, fake alarms should always be kept in mind while diagnosing ICA as detachment of electrodes, blood draws and electrocautery vastly outnumber the actual event.[7] Limited blood availability is another important issue significantly affecting the patient outcome in such cases. Since 1-3% of a nation's population can donate the blood, there should be an awareness campaign to raise the voluntary donor base.[8] Postoperatively, such cases require meticulous ICU care to minimize any further complication.

CONCLUSION

This case highlights the challenges confronted by anaesthetists while managing such critical scenarios. Initiating goal directed resuscitation along with early source control interventions remains the key to successful management of critically ill-patients with abdominal emergencies.