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: email@example.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.
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.
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.
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 . 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.
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
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
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 .
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
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 , 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 ; 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 . Our
patient benefited from rapid management, thus avoiding a lifethreatening
situation for her and her fetus.
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
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.
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