A Rare Case of Unsafe Abortion in COVID Times
1,2Department of Obstetrics and Gynaecology, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India
Corresponding Author: Sangeeta Pahwa, Department of Obstetrics and Gynaecology, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India, Phone: +91 9855080215, e-mail: firstname.lastname@example.org
How to cite this article: Pahwa S, Kaur S. A Rare Case of Unsafe Abortion in COVID Times. AMEI’s Curr Trends Diagn Treat 2021;5(2):99–101.
Source of support: Nil
Conflict of interest: None
A 29-year-old female, Para 3 Live2 with previous three cesarean sections presented in septic shock after undergoing unsafe abortion for intrauterine fetal demise at 5 months of amenorrhea by untrained person, diagnosed as intrauterine fetal demise at 5 months of amenorrhea. After the procedure, the patient underwent ultrasound which revealed fetal head in peritoneal cavity and perforation of the anterior uterine wall. On laparotomy, after retrieving the head from peritoneal cavity, perforation was found to be irreparable as well as the cecum, colon, and uterus were adherent. During hysterectomy, the cecum got perforated, cecal repair done followed by ileostomy. The patient was discharged in satisfactory condition.
Keywords: Fetal head, Hysterectomy, Ileostomy, Unsafe abortion.
An abortion is the expulsion or extraction of an embryo or fetus weighing 500 g or less from its mother when it is not capable of individual survival (World Health Organization, WHO).
The WHO defines unsafe abortion 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
When access to safe abortion is restricted, complications from unsafe abortion lead to morbidity and are a major cause of maternal death. Globally, it has been estimated that some 68,000 women die each year as a consequence of unsafe abortion, and 5.3 million suffer temporary or permanent disability.2
Every year, worldwide, about 42 million women with unintended pregnancies choose abortion, and nearly half of these procedures, 20 million, are unsafe.
Between 2015 and 2019, on average, 73.3 million induced (safe and unsafe) abortions occurred worldwide each year. There were 39 induced abortions per 1000 women aged between 15 and 49 years. Three of 10 (29%) of all pregnancies, and 6 of 10 (61%) of all unintended pregnancies, ended in an induced abortion. Each year between 4.7 and 13.2% of maternal deaths can be attributed to unsafe abortion. Estimates from 2010 to 2014 showed that around 45% of all abortions were unsafe. Almost all of these unsafe abortions took place in developing countries.3
Corona virus pandemic has put a negative impact on maternal care. Access to safe abortion has been negatively impacted during crisis.
A Para 3 Live 2, 29-year-old woman with previous three cesarean sections diagnosed as intrauterine fetal death on ultrasound at 5 months of amenorrhea, underwent unsafe abortion, and went into septic shock. Ultrasound after procedure revealed fetal head in peritoneal cavity and rent on the anterior uterine wall. On presentation to tertiary care center, the patient was in shock with heart rate 130/min, blood pressure 86/60 mm of Hg, pallor was ++. On abdominal examination: abdomen was tense, distended, tenderness++ right > left, guarding +, rigidity +. On investigating, the patient had hemoglobin 7.5 g%, total leukocyte count 20100 per cubic millimeter, differential leukocyte count 80/16/02/02, renal function test within normal limits, liver function test within normal limits, normal serum electrolytes, urine output 40 mL/hour.
Ultrasound of pelvis revealed possibility of incomplete abortion with perforated uterus. Fetal head (corresponding to gestational age of 16 weeks 5 days), face, and upper cervical spine were seen anterior to the uterine body. Scalloping of fetal skull bones was seen (Fig. 1). For confirmation of ultrasonography findings, a contrast enhanced computed tomography scan of abdomen was done as per decision of radiologist which showed uterine perforation, extrauterine retained products of conception within the peritoneal cavity, and moderate degree of fluid in the peritoneal cavity.
After resuscitation with blood and blood products, laparotomy planned. On laparotomy, fetal head, face with peeled skin and upper cervical spine were retrieved from the peritoneal cavity (Fig. 2). No other fetal parts were found in the uterus or the peritoneal cavity. As rent on the anterior wall of uterus was found to be irreparable, the decision of hysterectomy was taken after taking consents (Figs 3 and 4). Omentum, ileum, cecum, appendix and ascending colon were seen adherent to the uterine wall, during hysterectomy cecum got perforated, cecal repair was done followed by ileostomy (Fig. 5). Patient was discharged in satisfactory condition after 2 weeks.
This case is an example of the iota of unsafe second trimester abortions happening in India. When untreated, they prove to be a grave cause of maternal morbidity and mortality. While abortion is still frowned upon by the society, the medical fraternity have to come together with the help of governmental reforms and show that abortion—whether first or second trimester—is accessible to all women, irrespective of the background they come from. When a woman nearly dies but survives a complication during pregnancy, childbirth or within 42 days of termination of pregnancy is defined as a “maternal near-miss.”4 Recent review on articles between January 2004 and December 2010 the prevalence rates of maternal near miss varied between 0.6% and 14.98% for disease-specific criteria, between 0.04% and 4.54% for management-based criteria and between 0.14% and 0.92% for organ-based dysfunction.5 Life-threatening conditions that constitute a near-miss include uterine dysfunction, that is, uterine hemorrhage or infection leading to hysterectomy.
The obstetrical bundle care in a tertiary hospital has to be activated—converting a miss case to a near-miss case and eventual survival. Two different set of teams are required to fulfill the need of urgent attention to a patient—a rapid response team (RRT) and a maternal code blue team. While the RRT is required when the patient is still responsive but there is a sudden deterioration in the patient’s status, the maternal code blue team’s need arrives when the patient is unresponsive with the need for cardiopulmonary resuscitation. The teams should practice the drill every month for better teamwork.
To address the need of critical care units within obstetric department, the concept of obstetric intensive care unit (ICU) and high dependency unit (HDU) is rolled out by the Government of India in 2016. With the inclusion of ICU/HDU in the maternal health-care model, it has become more robust defining appropriate care at every level of health system. Incentives should be offered to people working at grassroots levels for bringing such patients to higher centers. Contraception should be encouraged, permanent methods of sterilization such as tubectomy and vasectomy should be rewarded. Together, let us fulfill the SDG Target 3.1—reduction in the global maternal mortality rate (MMR) to less than 70 per 100,000 by 2030; and no country should have an MMR greater than 140 per 100,000.
USG: USG findings reveal possibility of incomplete abortion with perforated uterus
Fetal head, face, and upper cervical spine are seen anterior to the uterine body.
Fetal head corresponding to gestational age 16 week 5 days
Scalloping of fetal skull bones is seen. NC and CECT scan Abdomen
Uterine rupture extrauterine-retained products of conception within the peritoneal cavity
Moderate degree of fluid in peritoneal cavity
Visualized pelvic viscera, musculature, and the neurovascular structures appear to be unremarkable
Urinary bladder appears to be unremarkable. Wall thickness is normal
The WHO deems unsafe abortion as one of the easiest preventable causes of maternal mortality. Preventing unintended pregnancy, providing better access to health care, and liberalizing abortion laws to allow services to be openly provided can markedly decrease the rate of abortion-related mortality and morbidity.
1. Henshaw SK, Singh S, Haas T. The incidence of abortion worldwide. Int Fam Plann Persp 1999;25(Suppl):S30–S38. PMID: 14627053.
2. Henshaw SK, Singh S, Oye-Adeniran BA, et al. The incidence of induced abortion in Nigeria. Int Fam Plann Persp 1998; 24(4):156–164.
© The Author(s). 2021 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.