Keywords : perforation of fornix, criminal abortion
Mrs. X, a 35 year old gravida 8, para 6 was admitted with complaints of vaginal bleeding and something coming out of introitus on straining, following two attempt for abortion at 12weeks of gestation by a midwife.
On interrogation she gave a history of abortion at 12 weeks gestation by a midwife 20 days back. Following thisshe developed fever and bleeding per vaginum, which continued for 14 days. She went back to the same midwife because of those complaints. The midwife again performed some procedure to remove the retained products. She was not relieved of the above symptoms and also noticed something coming out of introitus on straining. She was advised by the midwife to consult a doctor. There was no history suggestive of bladder and bowel involvement.
On examination she was hemodynamically stable with pulse lOa/min, regular with normal volume, B.P. 100/ 60 mmHg, pallor and no fever. Cardiovascular was respiratory systems and RS were within normal limits. Abdominal examination revealed tenderness in hypogastrium and no palpable lump. Speculum examination showed a large mass mimicking the shape of the uterus filling the whole vagina giving the impression of acute inversion of the uterus.On vaginal examination a large soft to firm mass was felt filling the vagina. The cervix was lying on top of the mass and a cord like structure was felt between the mass and the cervix.
An abdominal ultrasound showed - Uterus of normal shape and size . A mixed echogenic mass of 75x66mm size was seen in the pelvis posterior to the uterus. No adenexal mass or free fluid were present in the cul-de-sac. A provisional diagnosis of complex pelvic mass was made.
Examination under anesthesia revealed that the mass was coming out of the abdominal cavity through 2.5 em tear in the posterior vaginal fornix.
At laparotomy, the greater omentum was seen entering into the vagina through the tear in the posterior vaginal fornix. Uterus, cervix and both adenexas were normal. The omentum was cut near its entry into the vagina and the varigated reddish yellow mass of about 8x6x4 em was delivered per vaginum. Other viscera were normal. Tear in the vagina was repaired in two layers. Tubal ligation was done. The abdomen was closed after peritoneal toilet.
Histopathological examination revealed products of conception attatched to omentum. She was kept on broad spectrum antibiotic and IV fluids for 2 days. Her postoperative period was uneventful. Stiches were removed on the seventh postoperative day and she was discharged.
Perforation is a potentially serious but infrequent complication of abortion. The reported incidence of perforation is about 0.2/100 suction curettage abortion' . Performance of curettage for abortion by a semiskilled individual rather than by a qualified obstetrician increases the risk more than five folds. The risk of perforation increases significantly with advancing gestational age . Multiparous woman have three times the risk of nulliparous woman", The two principal dangers of perforation are hemorrhage and damage to abdominal contents, that may require laparotomy. The long term effects of abortion are Rh sensitization and infertility".
