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February, 1998 >>

Complications Attributed to Illicit Abortions

Pages with reference to book, From 42 To 45

Rakhshan Shaheen Najmi  ( Department of Obstetrics and Gynaecology, Fatima Jinnah Medical College, Lahore. )

Abstract

A four year prospective study was carried out involving 83 cases of induced abortions, 72 were induced illegally and 11 weremedicallyindicated, to determine the incidenceand types of complications of illegally induced abortions as well as those of therapeutic ones. The prevalence of illegal abortion was 3.61% and that of therapeutic was 0.55%. In illegally induced group, age of 48(66.66%) women ranged between 21-35 years, 34 (47.22%) were grand multiparas and 79% were illiterate. In 31 (43.25%) women, illegal abortions were carried out by TBAs and the most commonly used method was instrumentation employed in 46 (63.88%) of cases. The commonest complication detected was haemorrhage occurred in 31(43.25%) patients, followed by sepsis in 24 (33.33%) and trauma in 13 (18%) cases. Indications of therapeutic abortions included maternal malignant diseases and fetal anomalies. Only one patient developed post abortal endometritis (JPMA 48:42, 1998).


Introduction

Illegally induced abortion is a major public health issue. WHO1 has coined a new term “Unsafe Abortions” characterized by the lack or inadequacy of skills of the providers, hazardous techniques and unsanitary facilities. According to WHO2atleast 20 million women undergo unsafe abortion annually and some 67000 women die while millions suffer chronic morbidities. In all the developing countries includingPakistan “Unsafe Abortions” mean illegally induced abortions which are usually performed clandestinely by back street abortionists. It is very difficult to give accurate figures of illegally induced abortions from the third world because the women will come to the hospitals only when some complications have developed, even though they am often unwilling to admit that they have had illicit abortions. According to a report the incidence of illegally induced abortions invarious parts of Nigeria3 ranged between 15-50%. A recent study4 from Karachi gave an incidence of 3.08%. Immediate complications of illicit abortions are haemorrhage, sepsis and visceral injuries and chronic disabilities include pelvic inflammatory disease, infertility and ectopic pregnancy.
About 9- 15%4-6 of maternal deaths in Pakistan are attributed to illegally induced abortions as quoted in different studies. In this study complications of induced abortions were presented to emphasize the fact that womens’ life and health are clearly threatened in unsafe abortions and majority of these disabilities are preventable.


Patients and Methods

This study was carried out in the Unit! of Department of Obstetrics and Gynaecology of Sir Ganga Ram Hospital, affiliated with Fatima Jinnah MediCal College, Lahore from July, 1992 to June, 1996. During this period there were 1993 abortion related admissions. Of the 1993 cases, 1909 were cases of spontaneous abortions, 72 illegally induced and 11 were therapeutic abortions. A woman was labeled as a case of illegally induced abortion only on voluntary confession. All the cases admitted with history of illicit abortions were asked questions regarding the status of abortionist, methods used and the reasons for agreeing to illegal abortions. An effort was made to determine their awareness and attitude towards family planning services. Case files of the selected patients were examined carefully to record epidemiological variables, mode of presentation, nature and severity of the complications. Eleven cases of therapeutic abortions were studied to determine their indications, methods used and complications.


Results

During the period under review, 18978 pregnant patients were admitted in the said Unit I; of these, 1993 (10. 50%) were cases of abortions. Outof these 1993 abortions, 72 (3.6 1%) were illegally induced and 11 (0.55%) tenninations were carried out on medical grounds. Indications of therapeutic abortions included carcinoma of breast 6, osteosarcoma 1 and fetal anomalies 4 cases. According to

Table I maximum number of women, 48(66.66%) belonged to 21-35 year age group. Eighteen (25%) women wereof 36 years or above, youngest patient was of 15 years and the oldest one was 46 years. Parity of 34 (47.22%) was 5 or more and highest parity was 12. There were 3 nulliparas and one of them was unmarried. In 47 (65.27%) cases, there was history of previous one or more abortions. In 39 (54.16%) cases terminations were carried outwithin first trimester, the longest gestational period at which the abortion was done was 26 weeks. Only 15 (20.83%) women were literate and 61 (84.72%) belonged to poor and lower social classes. In Table II

various categories of abortionists and different methods used are depicted. 1n3 1 (43.05%)womeniliicitabortions were carried out by TBAs, in 26 (36.11%) by LHVs and in 14 (19.44%) by doctors. The method most commonly employed was instrumentation used in 46 (63.88%) cases followed by use of medicines in 13 (18%) women. Hormones were given orally and parenterally. Hethal preparations were given by TBAs orally in 3 patients and vaginally in 4 cases. Very foul smelling sticks were removed from the vagina and/or the uterine cavity in 6 patients placed by the TBAs.

In Table III details of complications resulting from illegally induced abortions were given. Vaginal bleeding was the presenting complaint of 31 (43.05%) patients, 9 came with severe bleeding and required emergency resuscitative measures and urgent blood transfusion. Of the 24 (33.33%) cases of sepsis, 7 had infection confined to uterus only. 11 developed pelvic peritonitis alongwith uterine infection and 6 came with septicemia. Eight patients had pelvic abscess formation. Of the 13 (18%) patients who came with visceral injuries, 8 were induced by TBAs, 4 by LHVs and the last one by doctor. Of these 13 cases, 6 presented with uterine perforation alone and 7 had combined uterine and gut injuries; of the 7 cases of combined uterine and gut injuries, 5 were caused by instrumentation and in the remaining 2 patients no cause could be detected. In3 cases gut was found to be pmlapsed invagina. Of the 7 cases of bowel injury 5 had ileal perforations, 1 combined ileal and sigmoid lacerations and the last one was with tearof sigmoid colon. One patient came with oliguria and another one had complete anuria. While one landed with cardiac failure and last one presented with deep jaundice. Forty (58.33%) patients presented within 72 hours of developing complications while 32 (40%) came after this this period. Reason of delayed presentation was the misguidance by the abortionists. There were 4 maternal deaths, multiple ileal perforations, septicernia, renal shut down and cardiac failure, each contributed one. During the study period illegally induced abortions accounted for 10.52% of these maternal deaths. Most of the women admitted that they were asked by their husbands to get rid of unwanted pregnancy. About 70% of the women were aware of some of the family planning methods and 27% had used one of the contraceptive measures. Most of them thoughtthatbirthcontml techniques caused alot of complications and were ineffective. As far as therapeutic abortions were concerned, age of the patients varied between 26- 32 years and parity from 3-5. Gestational age was <8 weeks inS cases, 9-14 in 4 and 16-17 in 2 patients. Seven had dilatation and curettage, 4 were induced with PGE2 vaginal tablets and in the remaining 2 cases extra amniotic instillation of PGF 2a was carried out. Only one patient developed post-abortal fever which settled down within a few days. This patient required repeated extra amniotic instillations of PGF2a.


Discussion

The incidence of illicit abortions detected in this study was 3.6 1%. According to two studies4-6 reported from Karachi, this figure was 3.08% and 2.34% respectively. The overall frequency of abortions was 10.50% and that of illegally induced abortions was 3.61%; in a study from Burma7 the corresponding figures were 32% and 73%. About 25% of women aged 36 years orabove and parity of 47% cases was 5 or more. In a study from JPMC6, Karachi the corresponding figures were 6.17% and 45.68%. Through effective famil planning counselling and services a significant reduction in the occurrence of illicit abortion in the said age and party groups could easily be achieved. In 54% cases, illegal terminations were carried out within first trimester while in a study4 from Civil Hospital. Karachi this was quoted to be 59%. According to this study 79% women were illiterate and 85%belonged to lowersocial class. History of previous one or more abortions was present in 65% of cases and in depth inquiry revealed that most of them were illegally induced. This figure has emphasized the fact that these women relied on abortion to end an unwanted pregnancy from the very beginning of their reproductive life and continued to do so. About 43% of illicit abortions were done by TBAs and in 64% cases some sort of instrumentation was carried Out. In this study 79% illegal terminations were conducted by TBAs/LHVs who were either untrained or inadequately trained; in an another study4 this figure was 62%. Of the 72 women with illegally induced abortions, 43% admitted with haemorrhage, 33% with sepsis and 18% with visceral injuries. The corresponding figures reported from two Karachi studies were 24%, 30%, 41%4 and 42%, 28%, 26%6 respectively.
According to a survey8 from several Nigerian hospitals about 85% of women admitted with illegally induced abortions were found to be complicated by sepsis. Complications of illegal terminations accounted for 1 1%of maternal mortalities during the study period. Most of the serious complications and mortalities occurred in those women who had terminations carried outby the unskilled personneland instrumentationwas the method employed for this purpose. Maternal deaths attributed to abortions was found to be 9%, 13% and 15%, in various studies4,6,9 from Pakistan. According to WHO10 abortion related complications are responsible foraround 14% of about half million maternal loss that occur each year, 99% of them in the developing countries. Reports from Nigeria3,11 revealed that illicit abortions had contributed significantly to maternal morbidity and mortality. A study from Burma7 reported that 50% of maternal mortalities occurred due to the complications of botched abortions. A seven fold increased risk12 of secondaiy infertility was documented in women with previous history of induced abortion. One important aspect of the scenario of the complications of illegally induced abortions is the under reporting of the cases due to legal, social and religious reasons13. This has been observed worldwide even in the developed countries14.


Conclusions

1) Although awareness regarding family planning was present in the study group but the information was incomplete and there was lack of effective counselling. 2) The causes of unsafe induced abortions are rooted in a complex set of socio-demographic circumstances. 3) Family planning services must be made available, accessible and affordable to all and the 4) Counselling strategies should be adapted to our circumstances in order to eliminate the induced abortion disasters 5) Incidence and associated complications of illegally induced abortions can be reduced through effective family planning services by improving wornens’ educational and social status, mass health education and legal sanction against backdoor abortionists.


References

1. The prevention and management of Unsafe Abortions. Geneva, WHO/MSM/1992, 5
2. Clinical management of abortion complications: A practical guide. Geneva, WHO/FHE/MSM/1941.
3. Adetero, U.O A 15 year study of illegally induced abortions at liorim Nigeria: lnt.J. Obstet. Gynaecol, 1989;29:65-72.
4. Tayyab, S. and Samad, N. Illegally induced abortions: A study of 37 cases. JCPSP.. 1996,6:104-106.
5. Najmi, R.S., Caesarean and post partum hysterectomy: A study from Lahore. JCPSP., 1994;4: 120-125.
6. Zaidi, S., Mastoor, S., Jaffery, H.F. et al. Maternal deaths in induced abortions. JCPSP.. 1993;3:20-23.
7. Kfi, M.K. Maternal mortality at South Okkalapa. Aust. N.Z.J. Obstet. Gynaecol., 1988,28:36-40.
8. Ladipo, O.A. Preventing and managing complications of indueed abortions in Third World countries. Int J. Gynaecol. Obstet. 1989;30:2 1-28.
9. Bashir, A. Maternal mortality in Faisalabad city: A longitudinal study. Gynaecologiat, 1993;3: 14-20.
10. A tabulation ofavailable data on thefrequency and mortality of unaafe abortions. Geneva, WHO/MCH/90.4, 1990.
11. Okonofua, FE., Onwudicgwa, U. and Odunsi, O.A. Illegal induced abortions. In depth atudy of 74 eaaes in Ife-ife, Nigeria. Trop. Doet., 1993;22 :75-78.
12. Okonofua, FE. Induced abortiont. A risk factor for infertility in Nigerian women. J. Obstet. Gynaecol., 1994; 14:272-276.
13. Tezan, S. and Omran, AR. Prevalence and reporting of abortions. Stud. Fam. Plann., 1981;12:262-271.
14. Jones, S.F and Forest, J.D. Under reporting of abortions in surveys of USA women. Demography, 1992;29:113-116.


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