Case Report

Placenta Accreta Spectrum; Different Management Approach. A Report of Two Cases

Soukaina Cherradi, Aziz Slaoui, Mariam Mahtate*, Khaoula Lakhdar, Najia Zeraidi, Amina Lakhdar and Aziz Baydada

Department of Gynecology Obstetrics and Endoscopy, University Mohammed V, Morocco

Submission: April 12, 2023; Published:May 02, 2023

*Corresponding author: Mariam Mahtate, Department of Gynecology Obstetrics and Endoscopy, University Mohammed V of Rabat, Morocco, Email: mariammahtate28@gmail.com

How to cite this article: Soukaina C, Aziz S, Mariam M, Khaoula L, Najia Z, Amina L, et al. Pelviperitonitis Due to Iatrogenic Perforation of the Uterus in the Context of Clandestine Abortion: A Case Report. Glob J Reprod Med. 2023; 10(1): 555777. DOI: 10.19080/GJORM.2023.10.555777.

Abstract

The clandestine abortion especially exercised in non-medical environment remains a problem of public health in the countries in way of development seen the rigorous legislation in these same countries, seen the complications which result from it increasing so the morbidity maternal mortality, such is the case in our observation in a young patient who has resorted to a clandestine abortion complicated of pelviperitonitis but what remains extraordinary in our case it is that the fetus is still alive.

Keywords: Clandestine abortion; Iatrogenic perforation; Pelviperitonitis

Background

Clandestine abortion is a public health issue in our country despite the efforts to promote sexual education and the availability of contraception in community health centers. Unsafe abortions, especially in developing countries, are still on the rise, according to global health institutions, where voluntary termination of pregnancy is still illegal, in Morocco, no statistical study has been found on the frequency of this health issue.

The most used methods are multiple and different from one country to another however they are all based on the appearance of uterine contractions and the opening of the gestational sac: piercing objects: metal rod the method used in our patient, knitting needle, vegetable rod, plants provoking the menstrual flow in the form of infusion to be drunk or enemas and tampons in intra vaginal. The most frequent reasons for consultation in gynecological emergencies are hemorrhagic syndrome and/or infection. The main risk in clandestine abortions are the complications caused by the methods used, threatening the vital and functional prognosis of the woman.

Abortions are routine health care procedures, they are safe if the methods recommended by the WHO are used, if the gestational age is appropriate, and if the person performing the abortion has the necessary skills. The lack of access to safe, timely, affordable, and respectful abortion care is a major public health and human rights issue.

Introduction

Unsafe clandestine abortion is still a public health problem in developing countries. This illegal practice in these countries is responsible for significant maternal mortality. Six out of ten unwanted pregnancies end in abortion. About 45% of all abortions are unsafe and 97% of these occur in developing countries [1]. Our case received in the gynecological emergency room illustrates the severity of unsafe clandestine abortion in a 28-year-old married patient who did not want this pregnancy and resorted to clandestine abortion, complicated by peritonitis due to uterine perforation. However, what remains exceptional in our case is that the anmiotic sac remained intact with a living fetus with positive cardiac activity.

Case Report

This is the case of a young 28-year-old female patient, with a precarious socio-economic level, married for 8 years, G4P3, with no particular pathological history, who consults in the gynecological emergencies of our structure for intense pelvic pain with metrorrhagia in the context of a voluntary interruption of pregnancy in non-medical conditions by the use of a metal rod with a pointed extremity through the vagina.

On clinical examination, the patient was normotensive, tachycardic at 120 bpm and febrile at 39°C. Abdominal examination showed a wooden abdomen with a Douglas‘cry on gynecological examination. The rest of the clinical examination was unremarkable. The patient benefited from an abdominopelvic ultrasound which showed an evolving monofetal pregnancy of 14 weeks, positive cardiac activity, normal quantity of amniotic fluid, with the presence of an anterior corporal defect of the uterus associated with a peritoneal effusion of medium abundance (Figure1).

We realized an abdominopelvic CT scan (Figure 2) which showed an anterior corporal continuity solution extended on 25 mm associated with a hemopurulent peritoneum of medium abundance with a pneumoperitoneum in the perihepatic and mesenteric zones seen on the CT images in favor of a Pelviperitonitis on iatrogenic uterine perforation. The patient benefited from a conditioning with the necessary resuscitation measures, an exploratory laparotomy was carried out objectifying a medium abandon hemoperitoneum mixed with pus (Figure 3) with presence at the anterior face of the uterus of a breach of 20 mm (Figure 4) where the omentum was sucked in.

The patient benefited from a careful repair of the uterine breach (Figure 5) with an abandoning lavage of the peritoneal cavity under wide spectrum antibiotic coverage and without interruption of the pregnancy.

The postoperative follow-up was simple with fetal heart activity always positive. The obstetrical ultrasound of control was without anomaly, the patient was followed for her pregnancy in our structure to the consultation of pregnancy at high risk with a psychological support.

Discussion

Abortion is a common, safe health care procedure when it is performed according to a method recommended by leading scientific societies, appropriate to the term of the pregnancy and when the person performing the abortion has the necessary skills. Global estimates from 2010 to 2014 show that 45% of all abortions are unsafe. The burden of unsafe abortion is highest in developing countries (97%). It is estimated that more than half of all unsafe abortions worldwide occur in Asia, primarily in South and Central Asia. In Latin America and Africa, the majority of abortions (about three-quarters) are unsafe. Nearly half of all abortions in Africa are performed under the most dangerous conditions [2].

Physical health risks associated with unsafe abortion include Infections, incomplete evacuation (tissue and products of pregnancy not completely removed or expelled from the uterus), hemorrhage, perforation of the uterus (when the uterus has been punctured by a sharp object) as our case report. In Morocco, there is no statistical study on the subject, so the 3.74% frequency of unsafe abortion found in a study conducted at the Moulay Ismail Meknes military hospital is not representative of the general Moroccan population. This is a retrospective study spread over a period of five years, from January 1, 2009 to December 30, 2014, which included 451 cases of patients who had unsafe abortions out of a total of 1,240 pregnancies treated in the gynecologyobstetrics department [3].

Over the age of 20, the majority of unsafe abortions are due to socio-economic problems associated with the major problems, the prohibition of abortion by law, as in the case of our patient, and the lack of contraceptive practice, especially in African countries. The reasons for consultation are dominated by the haemorrhagic syndrome and infection, especially in our case. A number of patients remain silent about the conditions of the abortion; our patient revealed the method used after the medical act of rescue accompanied by social assistance, hence the interest in psychological care.

Ultrasound has made a considerable diagnostic contribution to the complications of abortion, particularly in our case where the uterine rupture was clearly visible in the ultrasound images. In Africa, the abortion methods used are often crude and traumatic, as in our patient’s case by the introduction of a metallic wire intrauterine. In Madagascar, infectious complications, particularly peritonitis, dominated the clinical situation [4], as in the case of our patient who developed pelviperitonitis.

4 cases of peritonitis by uterine perforation were recorded among a continuous series of 101 complicated clandestine induced abortions treated at the Clinique Gynécologique et Obstétricale (CGO) of the Centre Hospitalier Universitaire of Dakar [5]; In 3 cases, the postoperative course was complicated by parietal suppuration, secondary peritonitis requiring reoperation, and ileomesenteric infarction, fortunately for our patient, the postoperative course was simple with fetal viability. Peritonitis secondary to clandestine induced abortion is a condition with a high mortality. In Madagascar, 15.1% died within 7 days of hospitalization, and 6.7% before surgery, for a total of 21.8% mortality. All of these deaths were due to septic shock [6]. Our patient benefited from rapid management, thus avoiding a lifethreatening situation for her and her fetus.

Conclusion

Complications of clandestine induced abortions are increasingly frequent. We reported the case of peritonitis caused by complicated uterine perforation, which had a favorable evolution for her and her fetus. This observation highlights the difficulties encountered by the gyneco-obstetrician, confronted with the reality of serious complications threatening the vital prognosis of the woman as well as functional complications related to a practice which is still clandestine in some countries, but which remains no less frequent in a context where diagnostic and therapeutic means are still lacking.

Thus, the prohibition of voluntary interruption of pregnancy and the lack of knowledge of contraceptive procedures by women in Morocco open the way to non-medicalized abortions whose consequences are sometimes dramatic as shown in our case. The fight against this global public health problem would only be possible through an open dialogue between women and the social, health and educational services regarding the means of contraception.

Guarantor of Submission

The corresponding author is the guarantor of submission.

Funding

There are no funding sources to be declared.

Availability of Data and Materials

Supporting material is available if further analysis is needed.

Consent for Publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editorin- Chief of this journal.

Ethics Approval and Consent to Participate

Ethics approval has been obtained to proceed with the current study. Written informed consent was obtained from the patient for participation in this publication.

References

1. WHO (2021). Accessed Fevrier 2023.
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3. Laghzaoui O (2016) Inventory of unsafe abortions: retrospective study of 451 cases treated in Moulay Ismail Military Hospital of instruction, Meknes, Morocco. Pan Afr Med J 24: 83.
4. Ravolamana Ralisata L, Rabenjamina EN, Razafintsalama DL, Rakotonandrianina E, Randrianjafisamindrakotroka NS (2001) Les peritonites et pelviperitonites post abortum au chu d’ androva mahajanga a propos de 28 cases. J Gynecole Obstel Biol Reprod 30: 282-287.
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6. Fenomanana MS, Rakotoarivony ST, Riel AM, Rekoronirina E, Andrianjatovo JJ, et al. (2009) Profil epidemiologique et therapeutique des pelviperitonites postabortives a la maternite du chu D’antananarivo Madagascar. Revue D Anesthesie Reanimation Et De Medecine D Urgence 1(2): 17-20.