Total Ileal Resection with Right Hemicolectomy Following Unsafe Abortion: Unusual Ileojejunal Prolapse

Abstract

Background: Unsafe abortion accounts for 13% of maternal mortality in Africa. Most of these abortions are performed by unskilled practitioners, which often results in complications, including bowel injury. This case is reported because of the unusual presentation of the bowel injury-prolapse of a cut end of the bowel through the cervix via a fundal laceration-and the extensive bowel surgery performed. Case: A case of unsafe abortion complicated by uterine perforation, with injury to the small bowel and shock, is presented. The patient presented with 1.5m of gangrenous ileum extruded through the cervix via a laceration in the fundus of the uterus. She had exploratory laparotomy with uterine repair, jejunal resection, total ileal resection, right hemicolectomy, and colonojejunal anastomosis. Results: Her complications were managed successfully. Conclusions: Much needs to be done in the area of health education, improvement of health care services, and changes in the restrictive abortion laws, so as to stem the tide of death caused by unsafe abortion.

Full text

Case Report
Total Ileal Resection with Right Hemicolectomy Following
Unsafe Abortion: Unusual Ileojejunal Prolapse
Olufemi Aworinde, MBBS,
1
Ifeoluwa Oyetunji, MBBS, FWACS, FMCOG,
1
Kehinde Olufemi-Aworinde, MBBS,
2
Adebanjo Adeyemi, FWACS,
1
and Olusola Fasubaa, FWACS
1
Abstract
Background: Unsafe abortion accounts for 13% of maternal mortality in Africa. Most of these abortions are
performed by unskilled practitioners, which often results in complications, including bowel injury. This case is
reported because of the unusual presentation of the bowel injury—prolapse of a cut end of the bowel through the
cervix via a fundal laceration—and the extensive bowel surgery performed. Case: A case of unsafe abortion
complicated by uterine perforation, with injury to the small bowel and shock, is presented. The patient presented
with 1.5 m of gangrenous ileum extruded through the cervix via a laceration in the fundus of the uterus. She had
exploratory laparotomy with uterine repair, jejunal resection, total ileal resection, right hemicolectomy, and
colonojejunal anastomosis. Results: Her complications were managed successfully. Conclusions: Much needs to
be done in the area of health education, improvement of health care services, and changes in the restrictive
abortion laws, so as to stem the tide of death caused by unsafe abortion. ( J GYNECOL SURG 27:1)
Introduction
Unsafe abortion is a significant health problem and
an important cause of maternal morbidity and mortality
in developing countries.
1
Forty-two million induced abortions
are conducted annually worldwide, with 20 million being un-
safe abortions; of these, 610,000 occur in Nigeria.
2
Unsafe
abortion and its complications are responsible annually for
*70,000 deaths worldwide with >90% occurring in sub-
Saharan Africa; Nigeria accounts for 20,000 of annual deaths.
2
Unsafe abortion is defined as the termination of an unin-
tended pregnancy either by persons lacking the necessary
skills or in an environment lacking the minimal medical
standards, or both.
3
Recent reports support an increasing
trend in unsafe abortion without concomitant public policy
to reverse it.
4, 5
Abortion-related complications and death are usually
preventable, but in an environment where restrictive abor-
tion laws exist, overt complications such as uterine perfora-
tion with hemorrhage, bowel injury with gangrene, and
tetanus infection are common place because of individuals
who procure unsafe abortion in clandestine environments.
6
An unusual presentation of ileojejunal prolapse through
the cervix via a laceration in the uterine fundus following
unsafe abortion by an unskilled attendant, and the resultant
extensive bowel surgery performed, is reported.
Case
A 22-year-old married para 1 +1 (1 alive) was admitted via
the accident and emergency unit with protrusion of bowel
per vagina and generalized abdominal pain, 10 hours fol-
lowing an abortion with sharp metallic objects, that took
place in a nonmedical facility. She had bled profusely and
had experienced dizziness but no fainting attack. The abor-
tion was procured at an estimated gestational age of 12
weeks; 6 weeks after confirmation with a urine pregnancy
test. The patient’s last pregnancy was 2 years previously.
On examination, the patient was found to be anxious,
sweating, and markedly pale. Pulse rate was 120 beats per
minute and blood pressure was 80/40 mm Hg. There was
generalized abdominal tenderness with guarding. Pelvic
examination revealed a blood- stained foul-smelling vulva
with *1.5 m of gangrenous ileum protruding per vagina
with no active bleeding (Figs. 1 and 2). Her cervix was 2 cm
dilated with traumatized edges. The vagina was normal. A
diagnosis of uterine perforation with bowel injury following
unsafe abortion was made. Hemoglobin concentration was
5 g/dL; electrolytes were within normal limits. The patient
was resuscitated with intravenous fluids and antibiotics;
had 3 units of whole blood transfused, and received tetanus
prophylaxis. She underwent an emergency exploratory
laparotomy.
1
Department of Obstetrics and Gynaecology and
2
Department of Haematology and Blood Transfusion, Obafemi Awolowo University
Teaching Hospitals Complex, Ile-Ife Osun State, Nigeria.
JOURNAL OF GYNECOLOGIC SURGERY
Volume 27, Number 3, 2011
ªMary Ann Liebert, Inc.
DOI: 10.1089/gyn.2011.0010
1

At surgery, there was hemoperitoneum of 1.5 L; 14-week
size uterus with transverse ragged laceration of the fundus
bleeding actively; 1.5 m of gangrenous ileum protruding
through the cervix via the uterine laceration; ragged edges of
the remaining ileum up to 4 cm from the ileocecal junction;
edematous distal jejunum with bleeding points *16 cm in
length; grossly normal ovaries, tubes, appendix and large
bowel; and no retained product of conception (Figs. 1–3). She
had uterine repair, jejunal resection (distal 16 cm), total ileal
resection, right hemicolectomy, and colonojejunal anasto-
mosis. She was continued on antibiotics.
She was discharged on the 10th postoperative day after
counseling on contraception and hospital delivery, and par-
enteral vitamin B
12
supplement. She was seen after 5 weeks
with no complaint.
Discussion
This case highlights the problem with unsafe abortion in
Africa. Abortion is legally prohibited in this country and
carries religious and social stigma.
7
This gives rise to its be-
ing performed in secret by untrained personnel in poorly
equipped facilities, with attendant complications. Factors
associated with high rates of abortion mortality and mor-
bidity in developing countries include inadequate access to
contraception, restrictive abortion laws, pervading negative
attitudes to abortion, and poor health infrastructures.
8
In their review of 9 cases of bowel prolapse following
uterine perforation seen in Sokoto, Ntia and Ekele
9
found
that the ileum was involved in 67% of the cases whereas the
uterine injury was on the fundus 78% of the time, which is
similar to what was found in this case. Unlike in the cases
reviewed, this patient presented within 10 hours of instru-
mentation and recovered with no anastomotic leakage.
9
In the case under review, the activity of the abortionist
resulted in a drain on the lean purse of the patient and her
family in terms of the cost of medical care, surgery, and
hospital stay; and caused a preventable strain on the hospital
facilities and surgeon. The case brings to the fore the need for
contraception and effective public policy to address the issue
of unsafe abortion.
Fortunately for this patient, she presented early at a ter-
tiary institution where the complications were managed
successfully. This is not always the case.
9
Poverty, coupled
with fear of legal recriminations, prevents those with com-
plications from seeking professional help on time.
10
Never-
theless; the surgery performed in this case disrupted the
enterohepatic circulation, vitamin B12 absorption, and water
reabsorption in the gut. This predisposed the patient to
megaloblastic anemia and diarrhea.
Conclusions
The issue of abortion remains a delicate one in Nigeria,
presenting a complex of moral and ethical dilemmas. In all
societies, however, no matter what the legal, moral, or cul-
tural status of abortion is, there are women who will seek to
terminate an unwanted pregnancy.
9
This abortion with
bowel injury highlights the persisting problem of unsafe
abortions in Nigeria. Bowel injury is a serious and life-
threatening complication in a case such as this, although
occurring in this patient in an unusual presentation.
More health education, improvement of healthcare ser-
vices, and changes in the restrictive abortion laws have to
FIG. 2. On presentation, second view of bowel prolapse.
FIG 1. On presentation, first view of bowel prolapse. FIG. 3. Close-up view of fundal injury.
2 AWORINDE ET AL.

occur to reduce the incidence of unsafe abortion and its at-
tendant morbidity and mortality.
Disclosure Statement
No competing financial conflicts exist.
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Address correspondence to:
Olufemi Aworinde, MBBS
Department of Obstetrics and Gynaecology
Obafemi Awolowo University Teaching Hospitals Complex
Ile-Ife Osun State 10000000
Nigeria
E-mail: aworindeolufemi@yahoo.com
ILEAL RESECTION AND HEMICOLECTOMY AFTER ABORTION 3