Keywords : foreign body ● perforation illegal abortion
Abortion is legal in India for over three decades, but access to safe abortion is still not available for a vast number of women living in the rural areas. We present an unusual case of illegal abortion carried out at home by an untrained person.
Mrs. MD 35 years old residing at village – Bhemava, at Nanded (Maharashtra) was admitted on 19th April 2003 with complaints of excessive foul smelling brownish vaginal discharge and post coital bleeding for four years. She was para four, with all full term vaginal deliveries at home. Her last child was seven years old. She had never used any contraceptive.
She was thin built with mild pallor and normal blood pressure. Abdominal examination revealed no abnormalities. Speculum examination revealed a 2x3 cm papillary growth on the posterior vaginal wall close to the cervix. There was cervical erosion and foul smelling brownish discharge coming from cervix. On bimanual examination the uterus was eight weeks size fixed and tender. A firm tender mass was palpated in the pouch of Douglas. Both the fornices were tender.
Her hemoglobin was 11.9 g/dL and white cell count 14000/mm3 with 60% neutrophils. Urine analysis revealed pus cell 6-8 / hpf. Pap smear showed severe inflammation. Ultrasound scan (abdominal and pelvic) showed right sided hydronephrosis without any calculus, 8.2x4.2x6.8 cm size uterus with copper – T in situ, and a tubo-ovarian mass with cystic foci and solid components on the left side of the uterus. In x-rays of the abdomen and the pelvis copper T was not seen.
Biopsy of vaginal growth, hysteroscopy and diagnostic laparoscopy were carried out on 20th April, 2003. Hysteroscopy revealed tufts of hairs in the uterine cavity and two long wooden sticks were seen sticking to the right lateral wall of the uterus. On diagnostic laparoscopy left sided tubo-ovarian mass was noted. Omentum, loops of ileum and colon were adherent to the right side and posterior surface of the uterus obscuring the view of right tube and ovary.
A provisional diagnosis of chronic pelvic inflammatory disease following illegal abortion was made and consent was taken for laparotomy, abdominal hysterectomy and removal of tubo-ovarian mass.
Laparotomy was carried out on 26th April, 2003. At laparotomy the uterus was retroverted and fixed, and the tips of two wooden sticks perforating its right lateral wall were seen just above the uterine artery. Dense adhesions of loops of ileum and omentum were present over the area. Left ovary was cystic, but no adhesion was noted on that side. Total abdominal hysterectomy with right salpingo–oophorectomy was done. Postoperative recovery was uneventful.
On repeated questions the patient revealed history of criminal abortion done four years back by some untrained “Dai” who had put sticks with hairs tied on their tips as abortifacient. She expelled the abortus but the sticks were retained.
The present case of illegal abortion highlights our failure to provide the services of safe abortion to women living in the rural areas.
Untrained persons use different types of sticks to induce illegal abortion. Cases have been reported where sticks were not expelled along with the abortus and led to serious complications such as septicemia and death. There have also been reports of expulsion of a stick through abdominal wall 6 months after criminal abortion1 and case of criminal abortion with ischiorectal abscess where the sticks had been retained for 2 ½ months 2.
In our case the sticks were retained for 4 years causing persistent vaginal discharge and formation of granulation tissue over the vault of the vagina. The tip of the sticks had perforated the lateral wall of the uterus but they did not pierce any major vessel or intestine hence the patient did not have any life threatening complication after the criminal abortion.
