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OJHAS: Vol. 4, Issue
1: (2005 Jan-Mar) |
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| Uterine Perforation
With Subtotal Small Bowel Prolapse – A Rare Complication of Dilatation and Curettage |
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Jagannath Mala
Sherigar, Registrar
Archana Darshit Dalal, Asst. Professor
Jitu R. Patel, Professor
Department of General Surgery,
Sheth V. S. General Hospital,
Sheth K. M. School of Post graduate Medicine & Research,
N. H. L. Municipal Medical College,
Ahmedabad, INDIA- 380 006.
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Address For Correspondence |
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Dr. Jagannath M. Sherigar
3 Geneva Gardens,
Stranmillis,
Belfast, BT9 5FY, UK
E-mail: jsmala@yahoo.com |
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| Sherigar JM, Dalal AD, Patel
JR. Uterine Perforation with subtotal small bowel prolapse –A rare complication of
dilatation and curettage. Online J Health Allied Scs.2005;1:6 |
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Submitted: Jan 8,
2005; Revised: Mar 19, 2005; Accepted: Apr 14, 2005; Published:
May 10, 2005 |
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| Abstract: |
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Uterine perforation is the well known complication of induced abortion. We
report a rare case of uterine perforation with subtotal prolapse of small bowel following
first trimester abortion by an unqualified physician. Early surgical exploration with
resection and anastomosis of bowel performed. Patient discharged uneventfully after
postoperative recovery.
Key Words: Abortion, Conception,
Mesentery, Curettage, Jejunum and Ileum |
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Incidence of uterine perforation
varies from 0.4 to 15 per 1000 abortions as reported by different studies.1
Although most uterine perforations at the time of curettage during first trimester
abortion go unrecognized and untreated serious complications do occur. Inexperienced
physicians have been reported to perforate the uterus more frequently than experienced
physicians.2 An illegal abortion by unqualified inexperienced hands without or
with minimal medical knowledge in rural society of developing countries is not uncommon.
Complications can endanger the life of mother if proper medical or surgical intervention
is not offered in time.
A 34 year old Indian lady, gravida
6, para 5 with 12 weeks gestation, presented with loops of bowel hanging at the introitus
following dilatation and curettage by an unqualified physician. She attended the accident
and emergency department of a tertiary referral hospital an hour and a half after the
procedure. There was no previous history of abortion or caesarian section. She was not on
any contraception.
On examination, the patient was very
anxious, hypotensive with pulse rate of 120 beats per minute. About four meters of small
bowel loops were seen protruding out at vaginal introitus. Full length of bowel loops were
bare tubes without any mesentery. Per vaginal examination revealed loops coming through
the cervical canal. Palpation of abdomen revealed signs of peritonitis. Given the clinical
findings, no imaging or sonogram could be done before the surgical procedure.
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Photograph showing resected coils of intestine |
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Patient was resuscitated with
crystalloids. She had an emergency laparotomy. Perforation was noted at the fundus with
loops of jejunum and ileum entering into the uterus. Mesentery was stripped off from the
bowel loops at mesenteric border without serious vascular disruption. There was about 500
ml of blood in the pelvis. Large bowel was intact. Remnants of the small bowel loops were
clamped and four meters of bowel was resected. End-to-end anastomosis was done with
remaining three feet of jejunum and two feet of ileum. Uterine perforation was sutured.
Mutilated fetus that migrated during curettage was found at right paracolic gutter.
Tubectomy was not done as the patient refused to give consent pre-operatively for
permanent sterilization. She recovered well following surgery. On follow-up ultrasonogram,
uterus showed no product of conception. Patient was discharged after a week with advice on
diet and family planning.
First trimester abortion is a
simple and commonly performed procedure. However several complications can arise. Early
complications include uterine perforations, blood loss, retained product of conception,
postabortal secondary hemorrhage, endometritis, pelvic infections and peritonitis. Late
complications are less defined and may include secondary infertility, ectopic pregnancy,
cervical incompetence, endometrial synechiae and endometriosis.5 Uterine
perforations are usually recognized at the time of the procedure. In case of first
trimester fundal perforation, observation is all that is required. In rare cases, in
addition to colonic and small bowel perforations, bowel, ureter or fallopian tube may be
inadvertently aspirated during abortion. Surgical intervention should not be delayed in
such cases. The important determinants of this complication are the skill of the physician
and the position of the uterus with a much greater likelihood of perforation if the uterus
is retroverted.
In our case curettage was done by an
unqualified physician. Lack of education, social stigma and other barriers to abortion,
force women to seek abortion in secrecy at a high cost, leaving the poorest, least
educated women to unskilled and highly unscrupulous executors and hence the greatest risk
of injury. Abortion when legal should be safe. The most effective way to reduce the number
of morbidity and mortality would be to prevent unwanted pregnancies by informed and
effective use of contraception. Easy accessibility of abortion services, curb on
unauthorized medical practice can reduce the complication rate.
Extensive research indicates that induced
abortion continues to be a procedure requested by women. It is important for health care
provider to understand the process of induced abortion to recognize the potential risks,
benefits and complication of this procedure. It is an obligation of medical profession to
keep it safe.
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Nathan BN. Management of uterine perforations suffered at
elective abortion. Am J Obstet Gynecol 1972;114(8):1054-1059.
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Grimes DA, Schulz KF,
Cates WJ. Prevention of uterine perforation during curettage abortion. JAMA 1984;251(16):2108-2111.
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Scott JR, Disaia
PJ, Hammond CB et al. Induced abortion In: Danforths Obstetrics and Gynecology. Lippincott
Williams and Wilkins 1997:567.
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Odlind V. Induced abortion – A
global health problem. Act Obstet Gynecol Scand 1997;164(76):43-45.
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Chen LH, Lai SF, Lee
WH et al. Uterine
perforation during elective first trimester abortions: A 13 year review. Singapore Med
J 1995;36:63-67.
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