Satia MN*, Ganapathi T**, Mali K***
(* Professor, ** Third Year Resident, *** Assistant Professor. Department of Obstetrics and Gynecology, Seth G S Medical College & KEM Hospital, Mumbai, India.)
Abortion is an important health concern in women but increasingly governed by the patriarchal interest which curbs the freedom of women who seek abortion as a right. Illegal unsafe abortion remains an alternative for the poor, widow and the unmarried. These unsafe abortions pose a great danger to the life of the patient. Our present case is an illustration of complication of abortion resulting in uterine perforation, bowel injury and hystero-ileal fistula. In our case per rectal examination was normal, there were no signs of injury to the perineum yet the patient was passing feces through the vagina.
As per WHO one woman in every 8 minute dies in developing nations due to morbidity arising from unsafe or illegal abortion, making it one of the most important cause of maternal mortality. Five million women suffer injury as a result of morbidity arising from unsafe or illegal abortion. The risk of bleeding requiring transfusion following an abortion is less than 1 in 1000, risk of uterine perforation is 1-4 in 1000 and risk of cervical trauma to the external os is 1 in 100. During suction and evacuation the surgeon is operating blindly, by sense of feel. If manipulation of the surgical instrument is done carelessly or forcibly, uterus and even her bladder or bowel can be perforated. Failure to diagnose uterine perforation may lead to major complications & these patients usually present to the emergency surgical unit with increased abdominal pain, bleeding and fever. The presence of pain during rectal examination and bleeding through rectum makes the diagnosis of post abortion bowel injury almost certain. In post abortion patients with abdominal pain beyond the pelvic area, suspect perforation and evaluation should include upright radiographs, pelvic sonography & computed tomography (CT) scan. If suspicion is high, diagnostic laparoscopy should be done.
A 20 year old unmarried woman came to the emergency surgical unit with complaints of passage of feces through the vagina since 10 days. She had 2 months of amenorrhea with history of fever associated with giddiness for which she was given intravenous fluids along with multivitamin injection by a general practitioner following which she was referred to a higher center for medical termination of pregnancy on request. When she came to our hospital she gave history of a spontaneous abortion of 2 months gestation following an accidental fall 20-25 days ago. She denied history of medical termination of pregnancy or any instrumentation done for the same. She had history of fever associated with giddiness. On admission, she was febrile, had tachycardia with a pulse of 110/ minute and blood pressure of 100/70 mm of Hg. On abdominal examination, there was mild distension, tenderness in the hypogastrium and feeble peristalsis. On speculum examination, cervix could not be visualized due to semisolid fecal matter persistently filling the vagina. There was no bleeding. On vaginal examination, the uterus was soft, about 10 weeks in size, os was admitting tip of the finger, feces was flowing out from the os. There was no palpable rent in the vagina. On rectal examination, rectal mucosa was intact and there was no evidence of fourth degree perineal tear. A clinical impression of utero-intestinal fistula was made and sonography was advised which revealed a normal uterus and adnexa without any evidence of free fluid in the peritoneal cavity. In view of the inconclusive findings of sonography, CT scan of the abdomen and pelvis with anal contrast was advised. The CT scan was suggestive of a communication between the ileum and the uterus along with dilatation of the proximal bowel loops, with bowel adhered to the fundus of the uterus and no plane of cleavage between them. The contrast was seen flowing through the bowel into the uterus and filling the vagina. An emergency exploratory laparotomy was performed jointly by surgeons and gynecologists. On entering the peritoneal cavity small bowel loops were found to be dilated and adhered to the fundus of the uterus. There was minimal free fluid in the peritoneal cavity and no evidence of peritonitis. There was no fecal material in the peritoneal cavity. Adhesiolysis was done to release the bowel loops. On examination, 3 perforations of about 1.5 cm each, 7-10 cms apart were seen in the ileum. Loops of ileum was adherent to the uterus and the perforations were communicating with the uterine cavity via a rent of 3x3 cm in the uterine fundus.
Figure 1. Red arrow showing uterine rent of 3x3 cm and black arrow showing ileal perforation.
Figure 2. Black arrow showing the uterine rent of 3x3 cm at the level of fundus of the uterus.
She probably concealed the history of instrumentation for abortion, but intra operative findings were more in favor of a probable unsafe abortion by an untrained person leading to bowel injury and fistula formation. Bilateral fallopian tubes and ovaries were healthy. The uterine cavity was flushed with normal saline and all fecal material was suctioned out. No products of conception were found. The uterine rent was closed in a simple interrupted manner using polyglactin No. 1 sutures. Hemostasis was checked at the suture site. Resection anastomosis of the ileum with double barrel ileostomy was done. Postoperatively she was stable. She was put on higher antibiotics. She was started on oral fluids after 72 hours. She was discharged with the temporary stoma and was asked to follow up for stoma removal after 6-8weeks.
Around 10 women out of 100 undergoing medical termination of pregnancy develop immediate complications postoperatively. One-fifth (2%) of these complications are major complications. Major risks and complications of abortion are described extensively in the medical literature. Every year 21.6 million unsafe abortions are estimated to take place, mainly in the developing countries resulting in the death of approximately 47000 women. The MTP act was enacted mainly to reduce illegal unsafe abortions and to reduce the complications leading to morbidity and mortality. Immediate complications of unsafe abortion like hemorrhage, sepsis, injury to the uterus, bladder or bowel, shock and death can occur. MTP done by unskilled and untrained persons without knowledge and aseptic precautions lead to complications right from visceral injuries, genital fistulas, septicaemia to death. If major blood vessel is injured during perforation patients may present with hypovolemic shock. Bowel injury can occur along with uterine perforation. If initially unrecognized, patients present with nausea, and vomiting, pain in abdomen with distension & sometimes fever. Monitoring vital parameters is essential for patients with post abortion complications. Increasing fever could be a sign of progressive infection, low blood pressure along with tachycardia are the signs of severe hemorrhage or septic shock. Patients with uterine perforation that are not diagnosed during the procedure usually present to the emergency services with increased abdominal pain, bleeding and fever. Minimal suprapubic tenderness is common in the post abortion period. Severe tenderness in the abdomen strongly indicates instrumental injury complications like perforation, bowel injury or bladder injury. Silent abdomen is a sign of peritonitis. Vaginal examination will help in assessing the amount of bleeding, source of bleeding whether uterine, cervical or vaginal. A digital rectal examination is recommended in patients in whom the bowel may have been injured. Tenderness on rectal examination and bleeding through rectum suggests possible bowel injury. In such patients thorough evaluation by sonography and contrast enhanced CT scans help in reaching an accurate diagnosis and planning the surgery. Depending on the site of perforation, number of perforations and the vascularity of the bowel segment, resection anastomosis with temporary stoma is done. In the postoperative period bleeding through vagina is checked and patient is called for stoma removal after 3 months. Stoma care is taught to the patient and relatives.
Unsafe abortions pose a life threatening situation & a threat to social development. It is a major public health problem especially in the developing world. Early diagnosis and intervention might provide better outcome. Therefore prompt referral to tertiary care centers as & when required and safe abortion services by trained & efficient personnel will go a long way in decreasing the complications.
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Satia MN, Ganapathi T, Mali K. A Rare Case Of Hystero-Ileal Fistula. JPGO 2016. Volume 3 No. 11. Available from: http://www.jpgo.org/2016/11/a-rare-case-of-hystero-ileal-fistula.html