Maternal mortality remains a battle to be won in India. Unsafe abortions contribute to 8.9 % of maternal mortality [1] and still prevail in India. Medical Termination of Pregnancy Act has been in existence since last four decades, yet remains unreachable to many.
A 20-year-old unmarried female presented in our emergency unit with foul smelling per vaginal discharge since 15 days, colicky pain in left lower abdomen, weakness and fever on and off during 5 months following abortion performed by a local quack with the help of wooden sticks 2 years ago. Post procedure, she had heavy bleeding for 15 days. Her menstrual cycles were regular, painless but heavy since last 2 years. Her last menstrual period was 2 weeks earlier. She was referred for linear foreign body in uterus. Her general condition was stable with normal vitals and normal systemic examination. On per abdominal examination minimal tenderness was present in left iliac fossa with a lump in abdomen up to 16 weeks size mostly deviated to the left side.
On local examination, old healed hymenal tears were present. Per speculum examination revealed patulous os and greenish foul-smelling discharge. Pelvic examination revealed 8 weeks anteverted uterus with restricted mobility felt separately. A left adnexal tender mass of 5 9 6 cm was present. Adhesions were felt on the left side.
All laboratory parameters were normal. Ultrasonography showed evidence of linear echogenic structure in upper uterine cavity measuring 7 cm in length. Its lower end was seen in right posterior myometrial wall of body, while its upper end appeared to perforate the fundus of uterus on left side and extending into left parametrium at left cornua.
An exploratory laparotomy was done after antibiotic coverage. Intraoperatively left uterine wall was adherent with anterior abdominal wall. Omental and small bowel adhesions were dissected with surgeon’s assistance as it appeared very friable. After separating the adhesions, uterine perforation at left cornual end was seen with two wooden sticks around 3 cm protruding out through it (Fig. 1). Sticks were pulled out through the perforation. There was shredding of the sticks due to degeneration. The total length of the two sticks were 7 cm each (Fig. 2). Uterine curettage was done to empty the uterine cavity of the degenerated wooden fibers. Uterine perforation sutured with vicryl no. 1-0 in an interrupted fashion. The left fallopian tube was edematous and slightly inflamed at the cornual end. The right tube was unremarkable. Both the ovaries appeared normal. Postoperative period was uneventful.
World Health Organization defines unsafe abortion as a procedure for terminating an unintended pregnancy either by individuals without the necessary skills or in an environment that does not conform to minimum medical standards, or both. According to World Health Organization nearly all unsafe abortions (97 %) are in developing countries [2]. Legalization of abortion on request is a necessary but insufficient step toward improving women’s health. This is indeed true in our country where abortion has been legalized since the last four decades, but cases like this still exist. Kore et al. [3] from Mumbai studied 27 cases over a period of 4 years with an incidence of septic abortion as 0.57 % while another study by Das et al. [4] had 122 cases with 34.66 % incidence of septic abortion.
There are innumerable ways in which criminal abortions are conducted. Insertion of wooden sticks in this case is one such example. The sticks here caused uterine perforation and resulted in surrounding fibrosis. There was no bowel injury which is a common associated morbidity when there is uterine perforation. Basic principles of management of a case of criminal abortion is to control sepsis, to remove source of infection, to give supportive therapy to bring back normal homeostatic and cellular mechanisms, and finally to assess response to treatment. Indications of surgery are injury to uterus, suspected bowel injuries, presence of foreign body in uterus or in abdomen, and unresponsive peritonitis suggestive of collection of pus.
In this case, an exploratory laparotomy instead of a laparoscopy was done as we were suspecting adhesions. This was the finding intraoperatively too. This was indeed a rare case of retained foreign body of this long duration with uterine perforation Thorough counseling was done at discharge regarding future obstetric career, child bearing, and risk of uterine rupture in future pregnancy. But existence of cases like this brings to light the reality of prevalence of practices of unsafe abortions in India in spite of four decades of legalization of MTPs. World Health Organization have advocated a public-health approach to addressing unsafe abortion, emphasizing the legalization of abortion, the training of medical personnel, and ensuring access to reproductive-health services [5]. A more integrated approach of bringing awareness to general public, involving local people and re-educating the health care providers, is the need of the hour.
