Keywords : criminal abortion, foreign body, intestinal obstruction
Various types of foreign bodies like laminaria japonica sticks, small-bore canula, vegetable sticks, intrauterine devices, bamboo sticks etc. have been used for inducing abortion by quacks in underprivileged areas of third world countries. These unsafe foreign bodies can perforate uterus and cause obstruction and perforation of intestines.
A 19-year-old unmarried female presented with abdominal pain off and on since 2 months. Pain had increased in severity along with multiple episodes of vomiting and distension of abdomen three days prior to hospitalization. She gave history of regular menstrual cycles and her last menstrual period was 15 days prior to hospitalization.
On examination she was thin, poorly nourished and severely pale. Her temperature was 1000F, pulse rate 140 per minute, blood pressure (BP): 90/60 mm of Hg, and respiratory rate 25 per minute. Abdomen was distended with diffuse tenderness, guarding and rigidity. Gynecological examination revealed no abnormality.
X-ray of the abdomen on anteroposterior view showed multiple air-fluid levels (Figure 1) and radio opaque shadow lying obliquely and extending from hypo- gastric to right lumbar region which was thought to be an artifact.
After resuscitation an emergency laparotomy was performed. There were multiple dilated small bowel loops twisted around an axis. On palpation this axis was found to be formed by a foreign body around which was found twisted and gangrenous ileum (Figure 2). There were multiple perforations in the jejunum and ileum which were sealed by interloop bowel adhesions.
Proximal end of foreign body was found inside the lumen of proximal jejunum. Dense adhesions were present between uterus and sigmoid colon, indicating sealed uterine perforation from where foreign body could have entered into the peritoneal cavity. There was sero-purulent collection of about 1.5 liters in the abdominal cavity. An iron foreign body of size 22x0.5 cm was removed after enterotomy from the proximal jejunum. Whole of gangrenous ileum was resected and proximal jejunostomy with distal mucus fistula was carried out.Postoperatively, she was given intravenously 8 hourly ceftriaxone 1g 8 hourly for 10 days, amikacin 500mg 8 hourly for 7 days and metronidazole 100 mg x 8 hourly for 10 days. Subsequently she was given cefixime 200 mg x 12 hourly for 5 days. Postoperative period was uneventful. In the post-operative period the patient admitted history of illegal abortion being attempted by a quack, for a pregnancy of 8 weeks 2 months prior to hospitalization. She concealed this even from her parents due to social stigma as she was unmarried. She was discharged on 18th day with the jejunostomy. She regularly came for follow up every 2 weeks. After 8 weeks of surgery jejunostomy closure was done necessitating 7 days hospitalization. When seen one month after discharge she was doing well.
A community based survey of 10000 women and 1200 providers done by Indian Council of Medical Research in 1989 reports that 38% of women were unaware that induced abortion could be legal or illegal and almost all women in villages with primary health centers (PHC) were unaware of the free services for voluntary abortions available at PHCs 1.
At the village level, induced abortion services are predominantly provided by traditional birth attendants, most of whom are illiterate women. The main reasons for seeking illegal abortions are financial strain, poverty, and social factors like an unmarried, widowed or separated marital status. An estimate contends a rate of three illegal abortions to one legal abortion, in rural areas and a corresponding ratio of 4-5:1 in urban areas2. This case is being reported because an unusual foreign body which was used for illegal abortion had perforated the uterus and gone in to the peritoneal cavity and later causing intestinal perforations which got sealed and by adhesions but resulted in intestinal obstruction gangrene of the ileum.
