Degloving Injury of Bowel: An Unheard Complication of Surgical Abortion

Abstract

Unsafe abortion is one of the leading causes of maternal mortality. Various types of intestinal injury in form of haematoma, perforation, contusion and transection have been reported. Degloving injury of intestine is one of the rarest complications. We report a case of 32-year-old lady Gravida 4, para 3 admitted with history of induced surgical abortion by a quack with degloving injury to bowel. Though there was no fecal soiling of peritoneal cavity but large segment of bowel was lost. She was managed by end ileostomy and discharged in stable condition.

Case Report

A 32-year-old lady, Gravida 4, para 3 presented to emergency department of Guru Teg Bahadur Hospital, Delhi, India with history of 3 month amenorrhea with bleeding per vaginum for past 2-3 days. She underwent some instrumentation for termination of pregnancy by a quack at village. There was no previous history of any abortion or caesarean section. On examination, her vitals were stable. Abdominal examination revealed no features of peritonitis but bowel sounds were absent. On local examination, about two meters of necrosed small intestine was seen hanging out through introitus. The wall of intestine was extremely thinned out, stretched and without mesentery. Per vaginum examination revealed bowel loops coming out through cervical os [Table/Fig-1]. A medico legal case was registered and patient was taken for emergency exploratory laprotomy after taking informed and written consent.

[Table/Fig-1]:

Resected necrosed mucosal segment of intestine.

Intraoperatively, about 400 cc of haemoperitoneum was present. There was no fecal soiling of abdominal cavity. Uterus was 6 weeks in size and a rent of about 5cms was present at fundus of uterus with loop of small intestine going through it [Table/Fig-2]. The loop of intestine was necrosed, thinned out and completely detached from mesentery with tears in serosal layer through which mucosa was pouting out. Necrosed part of intestine was clamped and cut abdominally and end ileostomy was performed. Remaining products of conception were removed through uterine rent under direct visualization. Uterine repair was done in two layers. Another small serosal tear was also seen in sigmoid colon which was also repaired. In the post op period patient had gaped wound that was allowed to heal by secondary intention. Patient was discharged after three weeks in stable condition. In follow up period patient was doing well.

[Table/Fig-2]:

Peroperative image of degloved intestinal mucosa (arrowhead) going inside the uterus through perforation (black arrow).

Discussion

Every year, worldwide, about 50 million women with unintended pregnancies choose abortion and nearly half of these procedures (20 million) are unsafe. Some 47,000 women die of unsafe abortion annually, making it one of the leading causes of maternal mortality (13%) [1–3]. In countries like India where abortion has been legalized for more than four decades, it is still not easily accessible to women. So, they are forced to approach paramedical workers or traditional healer to get rid of unwanted pregnancy. Unsafe abortions are one of the most neglected sexual and reproductive health problems leading to high morbidity and mortality. For every woman who dies, many more are left with stigmata of abortions such as infertility, chronic pelvic pain, bladder and bowel injury. Uterine perforation and bowel injuries are the most dreaded complications that arise after unsafe abortion. Intestinal injury can occur in form of perforation, hematoma, contusion or transection. Degloving injury of intestine is one of the rarest complications reported so far. It is defined as circumferential tear of seromuscular layer of intestine, which separates from underlying mucosa due to shearing forces and thinned out mucosa bulges away from serosa. Mostly it has been reported as a part of seat belt injury during road traffic accidents [4]. The mechanism of degloving is combination of focal blunt abdominal trauma associated with shearing force of sudden deceleration of vehicle. In literature, only one case series of degloving injury have been reported as a complication of surgical abortion [5].

Uterine perforation occurs more frequently than expected during surgical evacuation for termination of pregnancy. Kaali et al., reported that uterine perforation occurred in 1.98% of first trimester elective abortion [6]. Bowel perforation is a rare but serious complication of surgical abortion, which is usually seen when abortion is performed illegally by untrained persons [7]. The incidence of bowel injury has been reported from 5 to 18% cases in different studies [8,9]. This is attributed to poor training, lack of resources, fear of medico legal cases, social stigma and lack of strict rules which promotes such practices [10]. The bowel may be injured with the uterine curette, ovum forceps, uterine sound, or even the plastic cannula. Bowel perforation occurs when the posterior vaginal wall or uterus is perforated, allowing the instrument to pierce the underlying structures [11]. The ileum and sigmoid colon are the most commonly injured portions of the bowel due to their anatomic location [11–13]. An important aspect of degloving injury is that since there is no mucosal breach, patient may present late with or without features of peritonitis. In present case, the quack perforated the uterus near fundus with her instrument and caught hold of the gut loop. While pulling the products of conception out, the gut loop also got dragged inside through small uterine rent. The mucosal tube would have been easily pulled out while thick seromuscular layer remained in the abdominal cavity leading to degloving injury. Computed tomography scan is the preferred modality for diagnosing this type of injury, more sensitive than ultrasonography.

Conclusion

With the usage of mifepristone and misoprostol, abortions have become a safe and easy procedure. Though India has liberal laws on termination of pregnancy, illegal abortions still outnumber the legal ones. Complications like intestinal injuries are a major setback to our comprehensive abortion care services. Legalization alone is not sufficient, we also need to spread information, awareness and educate masses about importance of safe abortion techniques by trained personnel. Primary prevention of unintended pregnancies through contraceptive promotions will itself bring down the incidence of septic abortion thereby reducing the dreaded complications.

Financial or Other Competing Interests

None.