Enterouterine Fistula: A Rare Complication of an Unsafe Abortion

1. Associate Professor, Department of OBG, 2. Professor & HOD, Department of Surgery, 3. Associate Professor, Department of Surgery, 4. Professor, Department of OBG, S.N.M.C Campus, Navanagar, Bagalkot-587102, Karnataka, India.

Abstract

A 25 year old unmarried woman presented with the complaint of passing semiformed faecal matter per vaginum, 3 days following an unsafe abortion. An enterouterine fistula was suspected on clinical examination and during the investigations. At laparotomy, an ileal loop was found to be attached to the uterus over the fundus, posteriorly. An ileal mucosal injury of about 2cms was found along the antimesenteric border. A resection and an end to end anastomosis of the ileum was done and the uterine perforation was closed in two layers.

Unsafe abortion, Enterouterine fistula, ileal injury

INTRODUCTION
Unsafe abortions are a global problem. One woman, somewhere in the world, dies every minute from a complication which is related to pregnancy or childbirth. 99% of such deaths occur in the developing countries. Of the 46 million pregnancies that are terminated each year around the world, only about 60% are carried out under safe conditions (1),(2). An estimated 19 million unsafe abortions occur worldwide each year, resulting in the death of about 70,000 women (1),(2). The Medical Termination Of Pregnancy (MTP) Act has legalized abortions in India. Yet, unsafe abortions remain a significant cause of morbidity and mortality in India. Complications can endanger the life of the mother if a proper medical or surgical intervention is not offered in time. Here, we are reporting a rare case of an enterouterine fistula following a second trimester abortion which was done by an unqualified person.

Case Report

A 25 year old unmarried woman, P0L0A2, from a remote rural area, presented with a history of passing semiformed faecal matter through the vagina, 3 days following an abortion. A detailed questioning revealed a history of vaginal instrumentation for an amenorrhoea of 16 weeks, by an unqualified person. One week prior to the instrumentation, the patient had received oral medication for the termination of the pregnancy by the same quack, which had failed to abort. There was no history of pre or post abortal antibiotics. The patient was started on antibiotics, on admission to our hospital. Her past history was significant for a similar history of termination of pregnancy at 12 weeks of gestation, at the hands of a quack, one year back. The general condition of the patient was stable, except for mild pallor. A speculum examination revealed semiformed faecal matter coming through the os. The vaginal mucosal integrity was intact. An ultrasound examination showed no retained products within the uterus and it was inconclusive in localizing the fistula. A colonoscopic examination ruled out sigmoid and rectal fistulous openings. Based on the above clinical and investigation findings, an enterouterine fistula was suspected and the patient was taken up for laparotomy.

On laparotomy, a loop of the ileum was found to be adherent to the fundus posteriorly, near the left cornu of the uterus (Table/Fig 1). The ileum was dissected from the uterine attachment, which revealed an ileal mucosal injury along the antimesenteric border, of 2cms and a uterine perforation of 2-3cms over the fundus posteriorly, near the left cornu (Table/Fig 2). A resection and an end to end anastamosis of the ileum was done (Table/Fig 3). The uterineperforation was closed in two layers (Table/Fig 4). The patient was discharged on the 10th postoperative day without any complications. On follow up one month later, she was doing well with no complaints of vaginal discharge.

Discussion

The term, ‘unsafe abortion’ which was proposed by World Health Organization (WHO), means “abortion which is performed by people who lack the necessary skills or in an environment which lacks even the minimal medical standards or both� (3). It is one of the highly neglected problems of health care in the developing countries. Among the causes of maternal mortality in the developing countries, unsafe abortions account for 13% of the maternal deaths (4). The risk of death is estimated to be 1 in 270 unsafe abortion procedures (5),(6). In India, it accounts for about 41.9% of the maternal deaths (7). It has been estimated that in India, 70-89 women per 1,00,000 live births die from unsafe abortions. The risk of death is 1 in 250 procedures (8). An estimate contends a rate of three illegal abortions to one legal abortion in the rural areas and a corresponding ratio of 4-5:1 in the urban areas (9).

Although an unsafe abortion is entirely preventable, it remains a significant cause of maternal morbidity and mortality in the developing world (2). An unsafe abortion is mostly performed by untrained persons , chiefly dais and untrained midwives, with its antecedent complications (2). The complications include uterine perforations, blood loss, the retained products of conception, postabortal haemorrhage, endometritis, pelvic infections and peritonitis (2) An in2testinal perforation is a rare complication of an induced abortion. A bowel perforation occurs when the posterior vaginal wall or the uterus is violated, allowing the instrument to pierce the underlying structures. The ileum and the sigmoid colon are the most commonly injured portions of the bowel due to their anatomic locations (6),(10). Imoedemhe et al., (11) studied 16 cases of intestinal injuries following illegally induced abortions. They found 10 cases with terminal ileal injuries and six with colonic injuries.

In our case, we encountered the injury of the ileum during a second trimester abortion which was performed by an untrained person. An ileal loop was pulled into the uterine cavity through the uterine perforation by the instruments. The injury went unnoticed at the time of the abortion. The patient developed no signs of peritonitis as the ileal and the uterine perforations remained sealed off from the peritoneal cavity by forming a fistulous communication between them, presenting three days later with a faecal discharge from the vagina. Such small intestinal injuries are predominantly encountered in second trimester procedures which are due to the instruments or even due to the sharp foetal bony structures (12). Colonic injuries are predominantly encountered in the first trimester (6).

Conclusion

The main reasons for seeking illegal abortions are financial constraints, poverty and social factors like an unmarried, widowed or a separated marital status and lack of education. More than three decades into the legalization of abortions through the MTP act, abortions are still being performed at alarmingly high rates by untrained people, under unsafe conditions, contributing significantly to the maternal morbidity and the mortality rates of India. The incidence of an unsafe abortion is a reflection of the degree of the unmet needs in the family planning program. The key messages on the health education and the information regarding safe abortion options should go beyond the urban elite and they should reach the remote and the marginal communities of India. All attempts must be made to reduce the incidence of illegal abortions by stringent legislation, propaganda and by increasing the availability of contraceptives and abortion services. A timely recognition and an appropriate management can reduce the morbidity and the mortality.

DOI and Others

ID: JCDR/2012/4033:2459

Date of Submission: Jan 23, 2012
Date of Peer Review: Apr 14, 2012
Date of Acceptance: Aug 31, 2012
Date of Publishing: Sep 30, 2012