Dr. Namrata Gupta

Prof. Dr. Chanda Karki

Gynaecology/obstretics dept.

Ms. Limbu, 25 year old, unmarried girl presented in emergency dept. on 17th chaitra 066 at 1: 30 a.m

c/o-heavy menstrual bleeding- 2 days

headache and dizziness On eliciting she gave h/o amenorrhea for 2 months Patient also gave h/o previous irregular menses and

heavy bleeding during menstruation. No h/o pain abdomen, use of any medication or any

bleeding disorder. No h/o any contact or any other medical illness

(patient was reluctant in giving proper history)

All basic investigations were sent(including Urine pregnany test)

Inj Tranexemic acid 500 mg IV STAT was given.

IV Fluids were started.

GC- Ill- looking Pallor-+++(patient looked paper white) Vitals: T- 100°F, Pulse- 102/min,

B.P- 90/60mmhg

S/E: P/A- Soft, non- tender, BS+ve P/S- active bleeding++

- cervical os-open, cervical laceration, P/V- uterus- 12weeks size(approx), anteverted, cervical

os open, bleeding+ with passage of clots

Hb%- 6.2 gm%

Blood group: AB+ve

Total count- 22,100/mm3 (N- 84%, L- 15%)

Platelets: 1,30,000/mm3

Urine Pregnancy Test: POSITIVE All other investigations were within normal range

Patient admitted by 2:00 a.m Patient immediately shifted to OT

Whole blood transfusion was started

Examination under anesthesia(EUA) and Suction & evacuation(S&E) done at around 2:30 a.m

Operative findings:

P/V- Cervix lacerated

Os open

Bleeding ++

Plenty of Product of conception obtained and sent for HPE.

SEPTIC INCOMPLETE ABORTION WITH SEVERE

ANAEMIA

Patient monitored closely . IV fuilds and IV antibioitics (Megapen, Metron, and

gentamycin) given. IV Pint of whole blood transfused on POD and

POD1 Post transfusion Hb%- 11.3 gm%

Patient became afebrile on POD2 , blood pressure maintained and was discharged on POD4 .

Patient’s clinical examination and operative finding gave picture of unintended pregnancy which had been intervened by unsafe methods to induce abortion

But patient denied any such history till last day of her hospital stay.

The WHO defines an unsafe abortion as-

"any procedure to terminate an unintended pregnancy done either by people lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both."

The most common abortion complications are haemorrhage, shock, sepsis and intra-abdominal injury.

Left untreated, each can lead to death Medium and long-term complications range from

reproductive tract infections (RTI)- (20-30%) & pelvic inflammatory disease (PID)-(20-40% )to chronic pelvic pain and infertility.

Late complications include increased risk of ectopic pregnancy, miscarriage or premature delivery in subsequent pregnancies.

Each yr 75 million of women world-wide Each yr 75 million of women world-wide experience unwanted pregnancyexperience unwanted pregnancy

46 million women have induced abortions46 million women have induced abortions

Nearly 20 million of these are estimated to be Nearly 20 million of these are estimated to be unsafe.unsafe.

13% of total maternal death occur due to unsafe 13% of total maternal death occur due to unsafe abortion.abortion.

"WHO: Unsafe Abortion - The Preventable Pandemic".

The WHO reports that in developed regions, nearly all abortions (92%) are safe, whereas in developing countries, more than half (55%) are unsafe.

Maternal Mortality Ratio-

281/100,000 live births 281/100,000 live births (MMR study 2006)

Unintended Pregnancies 33% 33% (DHS, ORC Macro, 2002)

Contraceptive Prevalence Rate

44% 44% (DHS 2006) Total Fertility rate 3.6 3.6 (DHS 2006)

Background Abortion law was liberalised in Nepal in the month of

Chaitra 2058 (March 2002) after many years of intensive research and advocacy.

The law received royal Seal in September 2002. However, there was long delay of 15 months before the procedural order was approved on December 25, 2003.

Nepal began providing comprehensive abortion care (CAC) services in 2004

245 sites listed for providing services

704 Providers (doctors/Nurses) trained as a service providers

Services expanded to 75 districts.

Within three years time frame around 229,583 women were reported receiving safe and legal abortion services (with around 90% of contraceptive acceptance rate)

LISTED PROVIDERS LOGO LISTED SITES

Listing Certificates, Cost of services and logo should be hung in public place

According to the new law, only listed (trained) doctors or health workers can provide safe abortion services at listed (approved) health facilities, under the following conditions:

Within the first 12 weeks of pregnancy for any woman on her request. The permission of husband or guardian is not required for women above 16 years of age

Within the first 18 weeks of pregnancy in cases of rape and incest

At any time if the pregnancy poses danger to the life or physical or mental health of the pregnant woman or the foetus is seriously deformed and it is recommended by a doctor.

Abortion is not allowed under coercion Abortion is not allowed under coercion

Sex selective abortion is not allowedSex selective abortion is not allowed

Only listed Physicians/Health Workers Only listed Physicians/Health Workers registered in their respective councils are registered in their respective councils are authorisedauthorised

Only listed health institutions are authorisedOnly listed health institutions are authorised

Surgical: Manual vacuum aspiration-up to 12 weeks D+C-dilation and curettage-less used-1st

trimester D+E-Dilation +evacuation-2nd trimester

12-16 weeks

Prostaglandins E1 (Misoprostol- causes myometrial contractility & cervical softening)

Mifepristone + prostaglandins- 8-10 weeks

Methotrexate+prostaglandins-through week 9(rarely used)

Lack of knowledge about the abortion law. Lack of knowledge of approved CAC centres Inadequate access to safe and legal abortion

services Low economic status, abortion fee, Early marriage and child bearing Low decision making power of women on

abortion and poor supportive environment

While unsafe abortion is one of the most common causes of maternal deaths,

it is also the most easily preventable through the provision of, and access to, safe abortion services and care.

SAS/CAC service has become accessible and affordable to Nepalese women even at peripheral level.

CAC service has minimal complication and also gives the opportunity for contraception.

Demographic and Health Survey, Nepal 2006 show a steady decline in the Maternal Mortality Ratio (MMR) from 539 in 1996 to 281 in 2006. Legalization of abortion and provision of safe and legal abortion service may be one of the factors that may have contributed to this decline.

www.ipas.org ©2009 Ipas. UNICEF nepal ^ "WHO: Unsafe Abortion - The Preventable

Pandemic". http://www.who.int/reproductivehealth/publications/unsafe_abortion. Retrieved 2010-01-16. 

Kathmandu University Medical Journal (2009), Vol. 7, No. 1, Issue 25, 31-39

-Baseline survey on functioning of abortion services in government approved CAC centres in three pilot districts of Nepal Karki C1, Ojha M2, Rayamajhi RT3