Uterine Perforation as a Complication After Unsafe Abortion: Serial Case

The demand for abortion and the incidence of unsafe abortion are still very high. About 45% of all abortions worldwide are unsafe abortions. Unsafe abortion is still a public health problem and one of the causes of maternal morbidity and mortality. In this article, we report 2 cases of uterine perforation after provocation or induced abortion due to unwanted pregnancy. The diagnosis of uterine perforation was established by clinical suspicion and exploratory laparotomy. Many factors affect access to abortion and one of them is the law regarding abortion. Countries with almost no deaths from unsafe abortions are countries that allow abortion on demand without restrictions. Meanwhile, unsafe abortion can be prevented through prevention and control.


INTRODUCTION
The National Center for Health Statistics, the Centers for Disease Control and Prevention, and the World Health Organization all define abortion as pregnancy termination or loss before 20 weeks gestation or with a fetus delivered weighing < 500 gram. 1 Each year, there are 73.3 million induced (safe and unsafe) abortions occurred worldwide each year.Six out of ten unintended pregnancies end in induced abortion. 2Induced abortion is defined as the medical or surgical termination of pregnancy before the time of fetal viability.It can be classified into therapeutic abortion (for medical indications) and elective or voluntary abortion (not for medical reasons). 1Based on data from 2010 -2014, approximately 45% of all abortions worldwide were unsafe.Over half of unsafe abortions were in Asia, especially in the south and central Asia.In developed countries, it is estimated that 30 women die for every 100.000unsafe abortions.While in developing countries, it is rise to 220 deaths per 100.000unsafe abortions and 520 deaths per 100.000unsafe abortions in sub-Saharan Africa. 2

SERIAL CASES
We report 2 cases of uterine perforation after an induced abortion due to unwanted pregnancy at the Sanglah Central General Hospital Denpasar Bali for the period April 2020 and June 2020.Both cases were referral cases from a private hospital in Denpasar.The first case is a 21-year-old woman, unmarried, while the second case is a 27-year-old married woman.The last education of these two patients was high school and this was their first pregnancy.
The main complaints in the first case were lower abdominal pain, minimal vaginal bleeding, and cough.The patient previously underwent curettage at an unknown clinic.Two days after the curettage, the patient developed a fever.On physical examination, consciousness was compos mentis with blood pressure 100/70 mmHg, pulse 82 beats per minute, respiratory rate 20 breaths per minute, and temperature 38°C.There is anemic conjunctiva, tenderness in the abdomen, while the height of the uterine fundus is difficult to evaluate.On vaginal examination, positive slinger pain was found, the uterine corpus was difficult to evaluate, pain in the adnexal area and Douglas bulging cavity.On laboratory examination, the hemoglobin level was 8.95 g/dl, leukocytosis 34.030/uL, thrombocytosis 702.200/uL, increased procalcitonin levels (0.32 ng/ ml), and elevated liver enzymes (SGOT 77.8 U/L and SGPT 120, 4 U/L).
On transvaginal sonography examination, there was free fluid in the peritoneal cavity, the adnexa was difficult to evaluate, while the size of the uterus was still within normal limits.There is a strong suspicion of uterine perforation as the cause of acute abdominal pain accompanied by anemia and transaminitis.It was decided to perform an emergency exploratory laparotomy.Durante surgery found 1 liter of blood and blood clots in the peritoneal cavity.Bleeding originates from the perforated uterine fundus accompanied by necrosis around the perforation.The uterus has strong adhesions with the omentum, peritoneum, and cavity of Douglas.
It was decided to perform a supra-vaginal hysterectomy with left salphyngo-oophorectomy and adhesiolysis.

DISCUSSION
Each year, there are 73.3 million induced abortions occurred worldwide each year.Six out of ten unintended pregnancies end in induced abortion. 2Induced abortion is defined as the medical or surgical termination of pregnancy before the time of fetal viability.It can be classified into therapeutic abortion (for medical indications) and elective or voluntary abortion (not for medical reasons). 1Approximately 45% of all abortions worldwide were unsafe. 2 According to WHO, unsafe abortion remains a public health issue despite being one of the easiest preventable causes of maternal mortality and morbidity. 3safe abortion could complications such as incomplete abortion, hemorrhage, infection, uterine perforation, and damage to the genital tract or internal organ by inserting dangerous objects. 2 Uterine perforation and bowel injuries are the major complications following unsafe abortion.The incidence of uterine perforation reported varies from 0.4 to 15 per 1000 abortions.Most uterine perforations at the time of curettage during firsttrimester abortion go unrecognized and untreated, serious complications like hemorrhage, septicemia, septic shock, and visceral injuries do occur.These complications can ultimately lead to death due to a delay in presentation for adequate treatment. 3nography is a helpful modality in detecting retained products of conception.Diagnosis of uterine perforation and bowel injury is based on clinical suspicion especially in poor resource settings The second case complained of severe pain in the lower abdomen accompanied by vaginal bleeding.Previously, the patient experienced vaginal discharge and fever two days after an induced abortion at a clinic around Dalung, West Denpasar.The patient is conscious and on examination, blood pressure is 115/80 mmHg, a pulse is 106 x/min, respiratory rate is 20 x/min, and temperature is 37.5°C.Severe tenderness in the abdomen makes it difficult to assess the height of the uterine fundus.On vaginal examination, there was an odorous flux, a palpable mass accompanied by pain in the right adnexa, and free fluid was palpated in the Douglas cavity.Laboratory results showed leukocytosis 28.650/uL and hemoglobin 10.61 g/dl.Transvaginal sonography revealed a hypo-hyperechoic complex mass of 7.92 cm x 4.69 cm and free fluid.The size of the uterus is 8.13 cm x 4.81 cm, the thickness of the endometrium is 1.28 cm.It was concluded that there was an acute abdomen with a differential diagnosis of ectopic pregnancy and uterine perforation.Prepared immediately for exploratory laparotomy.
During the operation, he found severe adhesions to the posterior part of the uterus with the cecum and retroperitoneum.The right and left fallopian tubes and intestines are attached to the posterior of the uterus covered with pus.Uterine perforation was also found about 1.5 cm x 1 cm in the uterine fundus and suppurative appendix.
Surgery was performed together with digestive surgery to be able to perform adhesiolysis and necrotomies followed by a hysterectomy, bilateral salpingotomy, appendicectomy, and omentectomy.
Undertreatment, both cases of uterine perforation improved, there are no other complications, and were allowed to go home on the 6th postoperative day.where imaging modalities are not readily available. 3n this case, symptoms such as lower abdominal pain and vaginal bleeding after induced abortion together with physical examination and ultrasound results have increased the index of suspicion, to which laparotomy exploration provided the definitive diagnosis and treatment.
Abortion is one of the safest medical procedures if done following the WHO.A barrier to access safe abortion includes restrictive laws, poor availability of services, high cost, stigma, conscientious objection of healthcare providers, and unnecessary requirements. 2Based on WHO research, the broader the legal grounds for abortion, the fewer death there are from unsafe abortion.There is 6 main ground for allowing abortion applies in most countries: risk to life, rape or sexual abuse, serious fetal anomaly, the risk to physical and sometimes mental health, socialeconomic reasons, and on request.Countries with almost no deaths from unsafe abortion are those that allow abortion on request without restriction. 4 Indonesian legislation, regulations on abortion are contained in the 2 laws, namely the Code of Criminal Law and Health Law.Criminal Law did not explain the definition of abortions and kill (disable) the content.This prohibited all types of abortus and was not allowed by law for any reason.It is considered burdensome to the medical community who are forced to do provoked abortion to save the life of a mother.The development of legislation of provoked abortion criminalist can be found in Article 75 -78 of Law no.36 the Year 2009 where law prohibited all types of abortion except for medical indication.This included if alive of the mother is in danger, the child will be born is expected to experience a severe disability or can not live outside the womb, and also to rape the victim that may cause phycological trauma for the mother. 5The availability of safe abortion depends not only on permissive legislation but also on a permissive environment, political support, and the ability and willingness of health services and health professionals to make abortion available. 4safe abortion can be prevented through prevention and control.Strategies prevention of unsafe abortion can be divided into 4 levels.Primary prevention through effective contraception methods; sexuality education program for the adolescent; provide social protection for pregnant women who abandoned by their partner, family, and see abortion as their only means of survival; and offer a program for women with unintended pregnancies to continue their pregnancies to term and give their babies up for adoption rather than abortion. 6condary prevention is through the legalization of abortion laws.Liberalization of law has been followed by increased access to safe abortion and the rapid reduction of unsafe abortion and related mortality.Tertiary prevention refers to proper and prompt treatment complications of unsafe abortion.This includes the good quality of post-abortion care and the positive attitude of health providers.In many countries where abortion is a crime, women consulting abortion complications are discriminated and sometimes arrested by the police.Discrimination of women with abortion complications affects the severity of abortion morbidity and mortality.Quaternary prevention refers to helping prevent a repetition of abortion by providing family planning counseling, information about different effective contraception methods, and provided with the means to control their fertility. 6

CONCLUSION
The demand for abortion and the incidence of unsafe abortion are still very high.Approximately 45% of all abortions worldwide were unsafe.Unsafe abortion could complications such as incomplete abortion, hemorrhage, infection, uterine perforation, and damage to the genital tract or internal organ by inserting dangerous objects. 2 Uterine perforation and bowel injuries are the major complications.Most uterine perforations at the time of curettage during first-trimester abortion go unrecognized, untreated, and have a serious complication that leads to death. 3Abortion is one of the safest medical procedures if done following the WHO, but this has been restricted by: restrictive laws, poor availability of services, high cost, stigma, conscientious objection of healthcare providers, and unnecessary requirements. 2Unsafe abortion can be prevented through prevention and control

Figure 1 Figure 2
Figure 1 Haemoperitoneum with Pus is Discovered during Laparotomy