Anatolian Journal of Obstetrics & Gynecology ISSN: 1308-8254 Anatol J Obstet Gynecol 2010; 3: 3 ©2010 Kosus et al.; licensee ALKIM BASIN YAYIN Ltd.
Case report
Illegal abortion with matchsticks Nermin KOSUS, Aydin KOSUS, Aysel DERBENT, Nilgun OZTURK TURHAN Department of Obstetrics and Gynecology, Fatih University Faculty of Medicine, Ankara, Turkey
Address for Correspondence: Nermin KOSUS, MD Ostim Mah. 1290. Sok. Nevbahar Konutları A7 Blok, No: 43 Yenimahalle, Ankara, Turkey Tel: +90 505 6325023 Fax: +90 312 2213276 / +90 312 4098886 E-mail:
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Anatolian Journal of Obstetrics & Gynecology Illegal abortion with matchsticks Kosus et al. Case report Anatol J Obstet Gynecol 2010; 3: 3 www.AnJOG.com ISSN: 1308-8254 ©2010 Kosus et al.; licensee ALKIM BASIN YAYIN Ltd.
Received: 8.3.2010 Accepted: 21.4.2010 Published: 10.11.2010
ABSTRACT Morbidity and mortality due to unsafe abortion are high especially in developing countries. In this case, we present a case of self induced abortion by insertion of matchsticks into uterine cavity. A pregnant woman was admitted to our hospital due to pelvic pain, foul smelling vaginal discharge, fever, and chills. Ultrasonographic examination revealed 11-week intrauterine fetus without cardiac activity along with two long, hyperechogenic structures extending in to the uterine cavity from cervix. Laboratory work-up was not significant. Misoprostol was administered with the diagnosis of septic abortus. After expulsion of fetus, hyperechogenic bodies were seemed to be retained in the cavity along with the part of placental tissue. Dilatation and evacuation revealed matchsticks were the hyperechogenic structures. Broad spectrum antibiotics were continued postoperatively. Patient was discharged after uneventful recovery period. Key words: Abortion, matchstick, self-induced, pregnancy, termination.
Introduction
Case
Unsafe abortion is defined as the 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 [1]. Every year around 580 000 women die due to the complications of pregnancy and delivery according to World Health Organization (WHO) statistics [1] There is an annual rate of around 50 million abortions worldwide, one-third of which are ‘unsafe’ [1-2]. Unsafe abortion is estimated to account for 13% of all maternal deaths worldwide. About half of all deaths from unsafe abortion are in Asia, and most of the remainder (44%) are in Africa [3]. Morbidity is a much more common consequence of unsafe abortion than mortality. Complications include hemorrhage, sepsis, peritonitis, and trauma to the cervix, vagina, uterus, and abdominal organs. Up to 50% of women who have unsafe abortions are hospitalized for complications [4]. There are many unsafe methods used for abortion: oral and injectable medicines, vaginal preparations, intrauterine foreign bodies, and trauma to the abdomen. In this case, we report a woman who tried to induce abortion by self-insertion of matchsticks into uterine cavity.
A 31-year-old multiparous (G4 P3) pregnant woman with pelvic pain was admitted to emergency department. Vital signs were as follows: blood pressure, 110/80 mmHg; pulse, 96/min; temperature, 38.2°C. She had foul smelling vaginal discharge, chills and fever. Ultrasonographic examination revealed an 11-week intrauterine pregnancy without fetal cardiac activity. On one side of the gestational sac in the uterine cavity two long, thin, hyperechogenic structures were seen (Figure 1A). Patient was asked about these foreign bodies. She said that she know nothing about these and never used intrauterine device. Also she hadn’t any pelvic operation. Compatible with the diagnosis of septic abortion, foul smelling discharge and uterine tenderness was confirmed with bimanual pelvic examination. Laboratory work-up was not significant. Broad spectrum intravenous antibiotic regimen and misoprostol was ordered with the diagnosis of septic abortus. After expulsion of fetus and placenta, retention of placental tissue and foreign bodies were observed in ultrasonographic examination (Figure 1B). Curettage was performed. During procedure two matchsticks were removed
©2010 Kosus et al.; licensee ALKIM BASIN YAYIN Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licence which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited (http://creativecommons.org/licenses/by/3.0/).
Case report
Figure 1. A. Arrows are showing matchsticks seen in the cervical region before abortion. B. After incomplete abortion matchsticks are shown with arrows.
from uterine cavity. When asked again after operation, she admitted that she inserted these by herself to induce abortion several days ago. Broad spectrum intravenous antibiotics were continued and patient was discharged with oral antibiotics after 5 days of hospitalization.
Discussion Every year, 50 million abortions occur worldwide [1-2]. About 19-20 million of them are unsafe abortions and an estimated 68 000 women die as a result. A high proportion of maternal deaths caused by abortion are especially due to illegal unsafe abortion. Nearly all unsafe abortions (97%) are in developing countries [3]. In Africa and South-East Asia, death rates for illegal abortion are 680 and 283 per 100 000 abortions, respectively [5] For every death due to illegal abortion, 30 women will develop an infection or disability. Overall the total number of women who develop such complications is 300 million, of which more than a quarter are in developing countries [6]. In contrast, in developed countries where abortion is performed legally and ‘safely’, maternal mortality rate is very low. For example mortality rates in Canada 0.1, Holland 0.2, England 0.4, Denmark 0.5, USA 0.6 and Scotland 0.1 per 100 000 legal abortions [5]. Unsafe abortion is usually associated with complications such as, abnormal vaginal discharge and fever, septic abortion, septic shock which occur as a result of low resource setting including factors such as lack of sterile equipment, use of sharp or inappropriate objects. It was found that infection is seen in up to 51% of illegal abortions. The 1997 WHO report stated that of the 53 million pregnancies which had resulted in induced abortion, one-third of the abortions had been performed in unsafe and unsterile conditions [7]. Invasive methods, such as insertion of tubes or liquids into the uterus, were more successful compared to other 2
Kosus et al. Illegal abortion with matchsticks
methods. However, these more invasive methods are associated with increased risks. Foreign bodies inserted into the uterus to disrupt the pregnancy can damage the uterus and internal organs, including bowel. Coat hangers, knitting needles, flexible rubber catheter, and slippery elm bark were common methods. The bark would expand when moistened, causing the cervix to open. Abortion by abdominal massage is another method still used by traditional practitioners in South Pacific and Equatorial Africa. The vigorous pummeling of the woman’s lower abdomen is designed to disrupt the pregnancy but sometimes it bursts the uterus and kills the woman instead [8]. The most common reason for illegal abortion is unwanted pregnancy. In Turkey, according to results of Turkey Demographic Health Survey 2003, one in every 5 pregnancy is unplanned. In Turkey, termination of unwanted pregnancy before ten weeks of gestation is legal. There is one termination for every 9 birth (11.3%) in Turkey [9]. The most reason for induced abortion is unwanted pregnancy (in 40.7% of cases). And other reasons of requested abortion are having lactating small child, health problems, economic, social or family problems that forced women to induce abortion [9]. More proximate causes include poor access to contraceptives and contraceptive failure. Family planning programs are very important for prevention of unwanted pregnancy. In Turkey, according to 2003 data, among 71% of women who use a contraceptive method, only 43.1% uses a modern method [9]. The occurrence of pregnancy while practicing contraception is a way of assessing the success rate of family planning programs. In a study performed by the National Research Center of Population Growth of America, the main cause of unwanted pregnancy, which ultimately led to illegally-induced abortion, was failure in contraceptive use [10].
Anatol J Obstet Gynecol 2010; 3: 3
Anatolian Journal of Obstetrics & Gynecology | www.AnJOG.com In conclusion, unsafe abortion is an important social and public health problem that causes significant morbidity and mortality especially in developing world. Prompt diagnosis and appropriate intervention might provide better outcome as in our case. However, increasing legal access to abortion, education of partners, and easy access to modern contraceptive methods should be the primary measures that prevent social and medical problems related with ‘unsafe’ abortion practices.
References 1. Mundigo AI, Indriso C, and World Health Organization. Abortion in the developing world. 1999, London ; New York: Zed Books. 2. World Health Organization. Medical methods for termination of pregnancy. WHO Technical Report Series, 871. 1997, Geneva: World Health Organization (WHO). 3. World Health Organization. Unsafe abortion : global and regional estimates of the incidence of unsafe abortion and associated mortality in 2003. 5th ed. 2007, Geneva: World Health Organization. 4. Complications of abortion in developing countries. Popul Rep F 1980(7): F105-55. 5. Sharing responsibility: Women, society and abortion worldwide. 1999, New York, NY: The Alan Guttmacher Institute. 6. Cisse CT, Faye EO, Cisse ML, Kouedou D, and Diadhiou F. [Uterine perforation after an illegal abortion]. Med Trop (Mars) 1999; 59(4): 371-4. 7. World Health Organization. Division of Family Health. Maternal Health and Safe Motherhood Programme. The prevention and management of unsafe abortion : report of a technical working group, Geneva. 2006, Geneva, Switzerland, WHO, Division of Family Health,. 8. Ugboma HA and Akani CI. Abdominal massage: another cause of maternal mortality. Niger J Med 2004; 13(3): 259-62. 9. Hacettepe University Institute of Population Studies. The 2003 Turkey Demographic and Health Survey (TDHS-2003), Ankara, Turkey: Ministry of Health General Directorate of Mother and Child Health and Family Planning, State Planning Organization and European Union. 10. Majlessi F, Forooshani AR, and Shariat M. Prevalence of induced abortion and associated complications in women attending hospitals in Isfahan. East Mediterr Health J 2008; 14(1): 103-9.
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