Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case Series
Year : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : QR05 - QR08 Full Version

Experiences in Reproductive Health Services in COVID-19 Era: A Nightmare


Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52884.16375
Surinder Kaur, Preet Kamal, Sangeeta Pahwa, Ripan Bala

1. Assistant Professor, Department of Obstetrics and Gynaecology, SGRDIMSR, Amritsar, Punjab, India. 2. Associate Professor, Department of Obstetrics and Gynaecology, SGRDIMSR, Amritsar, Punjab, India. 3. Professor, Department of Obstetrics and Gynaecology, SGRDIMSR, Amritsar, Punjab, India. 4. Professor, Department of Obstetrics and Gynaecology, SGRDIMSR, Amritsar, Punjab, India.

Correspondence Address :
Dr Surinder Kaur,
F 345, Mata Kaulan Marg, Kashmir Avenue, Amritsar, Punjab, India.
E-mail: drsurinderkaur@yahoo.in

Abstract

With consistent efforts for the last four decades in the area of family planning, it had been a rare instance to receive emergencies with uterine perforation, gut injury, septicaemia, and multiorgan failure with unsafe surgical intervention. But Coronavirus Disease 2019 (COVID-19) pandemic has caused major disruption to the family planning information and services globally. These gaps have been due to breakdown in contraceptive supply chains, closure of primary healthcare and abortion clinics, diversion of staff from family planning services to COVID-19 response team and the poor response was also due to fear of infection in hospital. As a result, many unsafe abortions in the form of near-miss mortality nightmares were revisited. The present series is of five cases, done at a tertiary care teaching hospital wherein there was mismanagement of the abortion due to lack of expert services during the COVID-19 pandemic. Uterine perforation with sepsis was observed in all the patients with bowel injury in three and broad ligament haematoma in one patient. A comprehensive, women’s sexual health system response to address family planning services provision during pandemics is the need of the hour for India to avoid unwanted pregnancies and prevent additional mortality and morbidity in women.

Keywords

Haemoperitoneum, Hysterectomy, Ileostomy, Laparotomy, Unsafe abortion

Past global health emergencies show that access to safe abortion can be negatively impacted during crisis (1). The World Health Organisation (WHO) declared the outbreak of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) to be a public health emergency of international concern on 31st January 2020 (2).The world’s biggest lockdown to curb the novel coronavirus, imposed in March 2020 has left unprecedented, unseen rare experiences in all fields and family welfare services are no exception.

With four decades of consistent efforts in this area, the risk reduction was achieved in the occurrence of septic abortions, more too illegal with devastating maternal health affections. Various tools under WHO eligibility criteria were being implemented to avoid unplanned unwanted pregnancies. Even safe methods for medical and surgical abortions under the Medical Termination of Pregnancy (MTP) act and Prenatal Diagnostic Techniques (PNDT) act were practiced at large. Unsafe abortions can result in an overall adverse effect with complications such as procedure related excessive haemorrhage, uterine perforation and injury beyond it in genital tract, gastrointestinal tract and fulminant sepsis with multiorgan failure including renal dysfunction, which if not managed as acute emergency, can end in maternal death (3).

The outbreak engaged India’s public sector doctors and nurses in pandemic management, which disrupted everyday routine sterilisation procedures- the most preferred method of family planning. India’s army of community level women healthcare workers, who are “big motivators” amongst seekers of reproductive services, had been diverted and engaged for contact tracing of COVID-19 positive patients leading to a pullback in family planning services. It was also observed that more time at home had increased couple sexual activity and even may have increased intimate partner violence which sometimes extends to sexual coercion and assault resulting in unplanned pregnancies (4). Many such conceptions had poor access to safe abortion services. As a result, illegal interventions occurred and those who reported late suffered maternal morbidity and mortality.

Five such cases admitted as obstetrical emergencies at Sri Guru Ram Das Institute of Medical Sciences and Research (SGRDIMSR) Amritsar, a tertiary care centre in Punjab, India, was reported over the period from June to December 2020.

Case Report

Case 1

A P3L3; 40-year-old lady presented with shock and severe pain in the abdomen and vomiting nearly 24 hours after surgical intervention by the midwife for eight weeks gestation. Besides toxic look, her abdomen was tense, tender with bowel sounds absent.On per vaginal examination- uterus was bulky with marked forniceal tenderness and fullness. Ultrasound (USG) revealed a distended uterine cavity with significant fluid in the abdomen. Urine Pregnancy Testing (UPT) was positive, Haemoglobin (Hb)-6.0 gm%, beta-human chorionic gonadotropin (beta-hCG) 569 miu, serum electrolytes, renal and liver function tests done were within normal limits. Emergency laparotomy showed the peritoneal cavity full of foul-smelling pus and faecal matter. A perforation sized 3×2 cm was identified on the left posterior wall of the body uterus (Table/Fig 1). Ileum was injured 10-12 cm away from the ileocecal junction. Resection of gut with ileostomy and uterus repair was performed.The patient recovered and discharged on the 10th postoperative day. She reported for follow-up and was scheduled for ileostomy closure after one month.

Case 2

A 24-year-old G4P3L2 subject with previous 3 Lower Segment Caesarean Section (LSCS) presented in shock with history of amenorrhoea of five months and intrauterine foetal demise following attempted intervention to expedite expulsion by midwife by using presumably un-sterile technique following some oral medication. She came in emergency almost 16 hours after the procedure of induction. On examination, her pulse rate was 136/min, blood pressure was 86/60 mmHg and temperature was 101oF. Per speculum examination revealed foul-smelling pus-like discharge. Per vaginal examination showed cervix admitting two fingers,forniceal fullness and tenderness. On USG, foetal parts were lying in uterovesical pouch suggestive of uterine perforation and fluid in peritoneal cavity. Emergency laparotomy was done after taking high-risk consent. Intraoperatively, the foetus equivalent to 16-18 weeks was found lying anterior to uterus having extruded through a rent in the anterior uterine wall of approximately 5×5 cm (scar rupture) (Table/Fig 2); caecum and colon were adherent to the anterior wall of the uterus with haemorrhagic fluid in peritoneal cavity. Ileostomy with the caecal repair was done for caecal perforation.Since the patient was in shock, a life-saving subtotal hysterectomy was done after explaining its need and taking appropriate repeat consent. Patient remained in Intensive Care Unit (ICU) for three days and was discharged in satisfactory condition on the 10th day. The care for ileostomy and its plan for closure was explained, but she did not report for follow-up surgery thereafter.

Case 3

A 23-year-old young P1L1 patient was admitted in emergency with acute pain abdomen, bleeding Per Vaginum (PV) and retention of urine for one day.She gave history of attempted removal of retained placenta three days back following abortion done by midwife at 18 weeks gestation with Intra Uterine Death (IUD). She looked pale, febrile, dyspneic and dehydrated with a pulse rate of 150/min and blood pressure of 78/60 mmHg. Differential diagnosis of perforation was kept in mind, which was confirmed by USG showing a rent in the posterior wall with fluid collection in the abdomen. Patient was planned for an emergency laparotomy. The intraoperative findings showed abdominal cavity containing pus and faecal matter with a rent of 7×2 cm with ragged edges on the posterior wall of the uterus near fundus. There was a recto sigmoid injury which was repaired with an ileostomy and uterine rupture was repaired. The patient succumbed to multiorgan failure in ICU 36 hours postoperatively.

Case 4

A 35-year-old patient G3P2L2 with previous 2 LSCS came in shock 6-8 hours post evacuation. There was history of lactational amenorrhoea of four months and the patient got termination of pregnancy after its confirmation by the midwife. She was in haemorrhagic shock with haemoglobin of 4 gm/dL. USG revealed a uterine size of 13.3×6.8×5.4 cm with multiple air foci and a heterogenous hypoechoic area blood clot in right adnexa of a size 8.5×7.1×5.1 cm. Emergency laparotomy was planned. Intraoperatively two rents- one of 4 cm size and another 8 cm on posteriorlateral uterine wall were identified (Table/Fig 3). Haematoma was drained. The abdominal viscera were intact. Total abdominal hysterectomy with right salpingo-oophorectomy and left salpingectomy was done. The patient was discharged on 10th day and had an uneventful convalescence. She reported for follow-up after four weeks in good health.

Case 5

A 27-year-old patient P1L1A1 came in the emergency with fever, vomiting, diarrhoea, and pain abdomen. The patient was dyspneic and febrile at the time of admission. She gave history of intake of MTP pills and D&C for failed abortion by midwife 15 days back. On USG there was evidence of ragged anterior wall suggestive of injury or perforation, with big mass of mesenteric fat showing stranding suggestive of inflammatory changes. All laboratory tests were done {Total Leukocyte Count (TLC)-28400 cu.mm, Hb-8 gram%, serum electrolytes, renal and liver function tests done were within normal limits. High vaginal swab sent for culture and sensitivity}. Since, the patient was haemodynamically stable with no urinary or bowel problem, she was planned for conservative management under strict vigilance with adequate fluid resuscitation, broad spectrum antibiotics (second generation cephalosporins), metronidazole infusion and blood transfusion. This was followed later by oral antibiotics and anti-inflammatory medications. Her hospital stay was for 10 days and she was discharged on request after a review ultrasound which showed resolving abdominal mass and decreased TLC from 11,200/cu.mm after 10 days of hospital stay. She had a follow-up after seven days for change of medication.

Discussion

Abortion is a time-sensitive service, with delays and denials leading to unsafe abortions. If safe abortion services are restricted or are unavailable, people turn to unsafe means to terminate their pregnancies. Access to safe abortion was negatively impacted during the COVID-19 global health emergency (1).

Since accessibility to healthcare services especially related to family planning was either not available or at low priority in health stream during lockdown, many aspirants suffered. As per a study done by IPAS Development Foundation, in the first three months of COVID-19 lockdown, 47% of the estimated 3.9 million abortions meaning nearly 1.85 million that would have likely taken place under normal circumstances were compromised. An 80% of this, accounting to nearly a 1.5 million was due to lack of availability of medical abortion drugs at pharmacy stores and the rest nearly 20% were due to reduced access to healthcare facilities (5).

Due to uncertainty of reproductive healthcare provisions in pandemic- the services related to contraception and abortion took a back seat and was neglected by compulsion of COVID-19 load on hospital service (6). A United Nations Population Fund (UNFPA) technical note estimated that due to measures taken for COVID-19 containment, many women were not be able to use contraception and this would result in 7 million unintended pregnancies (7). As a result of COVID-19 pandemic there was also a dearth of infrastructure, skilled manpower and logistics which resulted in suboptimal functioning of the health systems (8). A lacunae was observed in the abortion services in our system due to changing guidelines and priorities, leading to life-threatening complications.

Bowel injury which is a serious and life-threatening complication was found in cases 1,2 and 3. In case no. 3 bowel injury was inflicted during manual removal of placenta by untrained Midwife. A similar case of rupture uterus with bowel injury was reported Akinola OI et al., in a young patient 28-year-old (P3L3) in which bowel injury was inflicted during manual removal of placenta and patient had to undergo right hemicolectomy and ileo transverse anastomosis with uterine repair and bilateral tubal ligation (9). However, there was no bowel injury in case no. 4, but the patient had a big broad ligament haematoma with irreparable rupture uterus for which hysterectomy was contemplated with right salpingo-oophorectomy and left salpingectomy. Another similar case was reported by Joshi SM in which the patient reported with shock and severe anaemia after evacuation at eight weeks of gestation (10). On laparotomy, a rent of 2 cm was detected in the posterior wall which was stitched and a hysterectomy saved.

Case no. 5 could be managed on conservative treatment with high generation antibiotics, blood transfusion and supportive therapy. One case of conservative management was also reported by Pillai KS et al., in which the patient reported with breathlessness, pain in the abdomen, and fever with pelvic abscess on 8th-day postevacuation (11). They took the help of laparoscopy and drained 100 mL of pus and treated with i.v. antibiotics in the ICU and was discharged in satisfactory condition.

The reason for these complications was that abortions they were done by unskilled workers in unhygienic conditions or due to non accessibility of safe abortion services during lockdown period (12),(13).

Family planning services provisions showed a decline as per figures from Health Management Information System (HIMS) (14). There was 36% reduction in use of first dose injectable contraceptive and 21% in IUD use from December 2019 to March 2020. There was also a deficient supply of condoms (15%); oral contraceptive pills (23%). The surgical abortions were less practiced by 28%. Elective tubal ligation and IUD insertions were deferred both in public and private sector due to strict COVID-19 protocols and due to adversely affected financial status of the public (8).

Due to lockdown many abortions that could have been medically managed had to be converted to surgical abortions and that too were carried out by untrained personals outside. The fear of contracting COVID-19 in the hospitals led to refusal amongst the patients to come for abortion services. All five of the cases suffered from avoidable complications of uterine perforation, haematoma, gut injury, shock and sepsis thereby increasing the morbidity and mortality in the reproductive age group. Uterine perforation with sepsis was observed in all the patients with bowel injury in three and broad ligament haematoma in one patient.

Despite all the above complications, four patients were saved due to a multidisciplinary approach in the tertiary care centre. So, the lesson is that one must safeguard the sexual rights of a woman to make appropriate contraceptive choices. There should be continuity of these services as “essential reproductive health services” even in a pandemic or other disastrous situation including expertise and infrastructure. Safe abortion services especially in high risks situations like previous caesarean sections are rightfully essential. Early diagnosis and management of complications to avoid mortality or near-miss situations due to illegal interventions is the need of the hour.

Conclusion

The COVID-19 pandemic had an unpredicted significant negative impact in low income countries like India, with maternal health and family planning taking a hard hit. COVID-19 broke down the already existent meagre system of family planning and abortion services. Continuity in services is needed even in times of pandemic. This would require a sustained effort on part of policy makers and health providers – both in the periphery and tertiary care centres. Ease of access to healthcare, contraception and safe abortion services with early management of complications can help a long way.

References

1.
Todd-Gher J, Shah PK. Abortion in the context of COVID-19: A human rights imperative. Sex Reprod Health Matters. 2020;28(1):25-30. Doi: 10.1080/26410397.2020.1758394. [crossref] [PubMed]
2.
Sharma KA, Zangmo R, Kumari A, Roy KK, Bharti J. Family planning and abortion services in COVID-19 pandemic. Taiwan J Obstet Gynecol. 2020;59(6):808-11. Doi: 10.1016/j.tjog.2020.09.005. Epub 2020 Sep 10. PMID: 33218393; PMCID: PMC7833030. [crossref] [PubMed]
3.
Oye-Adeniran BA, Umoh AV, Nnatu SN. Complications of unsafe abortion: A case study and the need for abortion law reform in Nigeria. Reprod Health Matters. 2002;10(19):18-21. Doi: 10.1016/s0968-8080(02)00024-1. PMID: 12369323. [crossref]
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DOI and Others

DOI: 10.7860/JCDR/2022/52884.16375

Date of Submission: Oct 18, 2021
Date of Peer Review: Dec 03, 2021
Date of Acceptance: Feb 17, 2022
Date of Publishing: May 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 19, 2021
• Manual Googling: Jan 20, 2022
• iThenticate Software: Apr 02, 2022 (7%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com