- March 21, 2016
- Posted by: emobile
- Category: Patient's Corner
Emobileclinic Patient’s corner
Induced labour is a deliberate termination of pregnancy. It may be therapeutic when there is a medical reasons for such intervention as it is permitted in spite of the laws of the country against such termination. An induced abortion is regarded as unsafe if it is performed by unqualified persons and /or under unhygienic condition.
Abortion is a preventable cause of maternal morbidity and mortality. It accounts for 40% of maternal death in Nigeria but globally, 68,000 women die each year as a consequence if unsafe abortion and 5.3 million suffer temporary or permanent disability. Induced abortion I’d widespread in Nigeria despite the restrictive abortion law policy with an estimate of 760,000 occurring annually. It cuts across various groups of women including, the young, the older, single or married, employed and unemployed.
Induced abortion stems from having an unwanted pregnancy. Several factors contributed to this and they include low level of contraceptive use, desire for smaller family, desire to pursue a career, covering up extramarital affairs etc.
Several reports have shown that induced abortion is most common among unmarried adolescents who seek abortion to stay or avoid shame. Most of them like the scenario painted in the morning, are not using any form of contraceptive either due to lack of knowledge or shame in accessing such facilities believed to be for married ones; or due to poor background and upbringing which make it accessing contraceptive unaffordable. It has been shown that educated and gainfully employed Nigerian women are better able to access safe abortion than their uneducated and poor counterparts. The earlier case was that of a girl raised by a single low-income woman.
Hemorrhage and sepsis are the most common immediate complications of induced abortion, accounting for majority of maternal mortalities from unsafe abortion in Africa. Sepsis leading to abscess formation results from post abortal infection due to retained products of conception, use of unsterile instruments to procure the abortion or from uterine perforation. Many studies in Nigeria have shown a high incidence of infection as an abortion related complications and the organism commonly found are vaginal comnensals and sexually transmitted organisms such as Neisseria gonorrhea and Chlamydia tranchomatis. In situation such as perforated gut,gram-negative organisms such as E-Coli and Clostridium welchii may be isolated. The culture report of our patient showed a mixed growth of coliforms.
The diagnosis of pelvic abscess following post-abortal sepsis in our patient was made based on the history of recent induced abortion, the presence of fever and gastrointestinal disturbance of passage of watery stools. Other symptoms of pelvic abscess collection include painful defecation, severe back pain, rectal pain,offensive vaginal discharge, signs of pelvic peritonitis and toxic shock. Ultrasound was used to confirm the presence of pelvic collection and also to rule out possibility of incomplete abortion that will require uterine evacuation. Other investigation necessary in management of these patients include full blood count and differentials,blood and urine specimen for culture, vaginal and cervical smears for microbiological studies. Further investigations for determining the full extent of the problem include urea and electrolyte status,abdominal and chest x-ray to exclude bowel perforation.
The main principles of management of pelvic are resuscitation antibiotics therapy and surgical intervention. Our patient was managed along this line. She commenced on intravenous fluids, analgesics and bed rest. She was given potent broad -spectrum intravenous antibiotics because she had being on multiple antibiotics regimen for some days before presenting. These resuscitative measures along with antibiotics should be commenced 8 to 12 hours before further treatments are given. She had exploratory laparotomy following the resuscitation because the clinical findings of a pelvic mass and the possibility of uterine perforation based on the history of instrumentation.
Laparotomy afforded direct visualization of pathology, adequate drainage of abscess and thorough peritoneal levage. Other surgical interventions that could be used for management of pelvic abscess is posterior colostomy. It advantages is that it is simple, safe and easy to perform and may be used for a poor surgical candidate. It disadvantage is that it cannot be used for loculated abscess as in this case . Hysterectomy may be done for severe and selected cases in which the uterus is badly perforated with considerable dead and gangrenous tissues. Long-term complications of pelvic abscess include chronic pelvic inflammatory disease associated with pelvic adhesions and residual abscess, tubal occlusion, infertility, ectopic gestation, mild-trimester spontaneous abortion and preterm delivery.
Morbidity and mortality arising from abortion are preventable as can be seen in developed countries that have liberal abortion laws. The laws in this country are still restrictive despite evidence that the procedure has only been driven under ground but still widespread. Alternative measures of reducing this morbidity and mortality due to abortion should be channeled to other efforts such as sex education, accessibility and affordability of the family planning services, adequate post abortal care for survivors and improvements in socioeconomic conditions in the country in general.
READ ''She was seen at the emergency ward at 28 weeks gestation. She complained of fever which started one week prior to presentation. The fever was intermittent, moderate to high grade''