Unsafe abortion is a global problem. It leads to many complications and can even endanger the patient's life. We came across a complication in which the abortionist pulled out 50 cm mucosa of the colon.
Mrs. S. K, a 26 year old, woman G4P2A2 reported to the Gynecology Department on 22nd January, 2002 with a history of amenorrhea of two and a half months for which an abortion was done by an untrained person 24 hours earlier. About 6 hours after her abortion she had a syncopal attack followed by vomiting and distension of the abdomen. She went to some doctor in the nearby village from where she was refered to our hospital.
The patient was looking toxic. She had tachycardia, low blood pressure and dehydration. The abdomen was distened and guarding was present. There was evidence of free fluid in the abdomen. An ultrasound examination revealed a bulky uterus. Massive free fluid was present in the peritoneal cavity. Therefore, a provisional diagnosis of perforation was made and a laparotomy was decided open.
On opening the abdomen, there was massive foul smelling hemoperitoneum. There were two horizonal rents of 3cm and 2 cm size in the fundal part of the uterus. Uterine curettage was done from a rent in the uterus . The uterine wound was stitched after freshening the edges. Tubal ligation was done. A loose fold of thin shining structure was floating in the abdominal cavity. An injury to the small gut was suspected and whole of the small gut was traced. A small serosal injury of small gut was seen 25 em away from ilieocaecal junction. Mucosa of the small gut was intact. On tracing the shining loose fold injury to sigmoid colon and descending colon upto the splenic flexure was diagnosed.
Also to our surprise the head of a 12 - 14 weeks fetus was lying in the pouch of Douglas. The untrained dai had perforated the uterine wall and the anterior wall of sigmoid colon and started pulling the mucosa of sigmoid and descending colon from the inner wall- probably in search of fetal head. This mucosa was floating freely in the cavity.
Sigmoid colon and whole of descending colon was removed and colostomy done. She was in shock for two hours postoperatively. Four units of blood were transfused. Colostomy wound started functioning on the fourth postoperative day. She will need a second stage surgery later for colostomy closure. Primary anastomosis of transverse colon with rectum was not possible due to the critical condition of the patient.
Intestinal perforation is a rare complication of induced abortion. It is most commonly seen in countries in which abortions are performed by people without proper ,training. Bowel perforation occurs when the posterior vaginal wall or uterus is violated, allowing the instrument to pierce the underlying structures. The ileum and sigmoid colon are the most commonly injured portions of the bowel due to their anatomic location'. Imoedemhe et aF studied 16 cases of intestinal injuries following illegally induced abortions. They found 10 cases with terminal ileal injuries and six with colonic injuries. In our case, we encountered the injury of sigmoid colon and descending colon in the second trimester. Colonic injuries are predominantly encountered in the first trimester. Morbidity and mortality are related to both gestational age and site of injury. Morbid and even potentially fatal complications can occur as a result of pregnancy termination. With second trimester procedures, perforation can result in injury to the abdominal viscera from perforating instruments or even from sharp fetal bony structures",
