International Journal of Gynecology and Obstetrics (2007) 96, 24–27

a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m

w w w. e l s e v i e r. c o m / l o c a t e / i j g o

CLINICAL ARTICLE

Bowel injury following induced abortion

R.S. Jhobta a,b,⁎, A.K. Attri b , A. Jhobta b
a
Indira Gandhi Medical College, Shimla, India
b
Department of General Surgery, Government Medical College and Hospital, Chandigarh, India

Received 4 April 2006; received in revised form 29 June 2006; accepted 19 July 2006

KEYWORDS Abstract
Bowel injury;
Abortion; Objective: Bowel injury is an uncommonly reported yet serious complication of induced abortion,
Illegal abortion which is often performed illegally by persons without any medical training in developing
countries. A sudden increase in cases prompted the authors to analyze this problem. Method: A
retrospective review was done of 11 cases of bowel injury following induced abortion seen over
2years at Government Medical College and Hospital, Chandigarh, India. Results: Young, married
women of low socioeconomic status with a strong preference for male children were the
predominant recipients of induced abortion in India. The terminal ileum and pelvic colon were
the most commonly injured portions of the bowel owing to their anatomic locations. Conclusion:
Preoperative resuscitation, then resection with exteriorization of bowel and thorough peritoneal
lavage, is the treatment for bowel injury incurred during induced abortion when the patient
presents late.
© 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd.

1. Introduction 2. Patients and methods

Abortion was legalized in India in 1972 through the Medical
Termination of Pregnancy Act (Act 19711) to provide women
with safe pregnancy termination performed by qualified
professionals at authorized health care centers. However,
the incidence of illegal abortions continues to be high and
the complications of such abortions have not shown any
decline. Nine women presenting with bowel injuries follow-
ing induced abortion in the course of 6months prompted the
authors to examine the factors contributing to this serious
complication.
⁎ Corresponding author. Tribhuvan, Opp. Mehta Petrol Pump,
Sanjauli, Shimla, (Himachal Pradesh) India. Tel.: +91 1772645805.
E-mail address: bhavuvasu@rediffmail.com (R.S. Jhobta).
A retrospective analysis was carried out from the computer-
ized admission records of all the women who were referred
to the emergency services of Government Medical College
and Hospital (GMCH), Chandigarh, India, between February
2000 and March 2002 with a history of induced abortion, and
who, on laparotomy, had a bowel injury associated with
perforation of the uterus and/or the lower genital tract.
Data concerning preoperative patient characteristics,
intraoperative management, and postoperative complica-
tions are shown in Tables 1–4. Attention was paid to
demographic profile, parity, duration of amenorrhea for
the index pregnancy, recorded history of induced abortion or
cesarean section, type and site of bowel injury, duration of
hospital stay and, above all, the status of the person who
performed the abortion. The case notes were generally
insufficient to provide reliable information on prenatal sex
determination leading to female feticide. Following clinical

0020-7292/$ - see front matter © 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd.
doi:10.1016/j.ijgo.2006.07.010
Bowel injury following induced abortion 25

Table 1 Demographic profile of women with bowel Table 2 Operative findings in women with bowel
perforation associated with illegal abortion in India perforation associated with illegal abortion in India
Characteristic Number of patients Finding Number of patients
(%) (n = 11) (%) (n = 11)
Age (years) Preoperative status
<20 1 (19) Shock a 8 (73)
20–29 7 (64) Anemia (Hemoglobin <10 gm/ 8 (73)
30–39 3 (27) 100ml)
Marital status Bleeding per vagina 9 (82)
Married 10 (91) Sepsis b 8 (73)
Unmarried 1 (9) Operative findings:
Socio-economic status Diffuse peritonitis 9 (82)
Lower class 7 (64) Fecal/purulent exudates 10 (91)
Middle class 3 (27) Site of bowel injury
Upper class 1 (9) Ileal 5 (45)
Geographic distribution Colonic 3 (27)
Rural 8 (73) Jejunal + colonic 3 (27)
Urban 3 (27) Site of uterine injures
Pregnancy duration (weeks) Anterior 2 (18)
<12 7 (64) Posterior 7 (84)
12–20 4 (36) Fundus 2 (18)
Living children Operative procedure
1 son, 1 daughter 5 (45) Resection with anastomosis 2 (18)
1 daughter 2 (18) Resection without anastomosis c 9 (82)
3 daughters, 1 son 1 (9) a
Systolic blood pressure <100 mm Hg, pulse rate >110/min,
5 daughters, 1 son 1 (9) respiratory rate >20/min and/or urine output <30 ml/h.
Status of the practitioner a b
Hyperthermia >38 °C, tachycardia, techypnea and/or white
Qualified obstetrician 0 cells count >12 × 109/l.
“Private doctor” (qualified?) 7 (64) c
Ileostomy/colostomy with mucus fistula Hartman's
“Nurse/Dai” (unqualified) 4 (36) procedure.
⁎One was unmarried and the other was primigravida.
a
As per MTP Act 19711.
performed by a qualified practitioner at an institution
approved by the competent authorities according to the
diagnosis, laboratory work, and adequate fluid resuscitation, law [1]. Although in each case the procedure used for
all patients underwent exploratory laparotomy through a pregnancy termination was reported as “dilatation and
midline incision in an emergency setting. The site and type of evacuation,” the details of the “criminal” or “clandestine”
bowel and uterine perforations were then identified and methods used were not recorded. The patients' median age
adequately managed (Table 2). (interquartile range [IQR]) was 26 years (16–32years); the
median duration between bowel injury and surgery was
3. Results

Of the 11 women who were admitted to the hospital during

Table 3 Relationship of bowel injury with uterine
the 2-year study period, 9 were admitted in the last
perforation and pregnancy duration
6months; and even more surprising, 6 of these 9 women
were admitted in February and March 2002. The demo- Characteristic Number of Number of
graphic profiles of the 11 women show that most were young, patients with patients with
married, and from the lower socio-economic classes of rural small-bowel large-bowel
areas in the states of Punjab and Haryana (Table 1). Among perforation perforation
the 5 women who had 1 son and 1 daughter, only 1 had a (%) (n = 5) (%) (n = 6)
history of induced abortion and cesarean section. On the
Site of uterine perforation a
other hand, the 2 women who had 1 daughter and no son had
Anterior 2 (40) 0
2 previous abortions each.
Posterior 2 (40) 5 (83)
None of the 11 abortions causing bowel injury had been
Fundus 1 (20) 1 (17)
performed at a government hospital, and none of the women
Pregnancy duration (weeks)
had been attended by a qualified obstetrician. While 7
< 12 3 (60) 4 (67)
abortions were done at a “private hospital” or nursing
> 12 2 (40) 2 (33)
center, the other 4 were done at some undefined place by a
a
“private doctor,” a “nurse,” or a “dai.” It could not be Three patients had multiple-site injuries, including the
determined whether a single of these abortions had been jejunum and colon.
26
Table 4 Postoperative complications
Complication Number of patients
(%) (n = 11)
Intra-abdominal collection 2 (18)
Respiratory complication 5 (45)
Septicemia 4 (36)
Wound infection 7 (64)
Burst abdomen 4 (36)
Anastomotic leak 3 (27)
Bed sores 2 (18)
Morbidity 9 (82)
Mortality 1 (9)
2days (1–21days); and the median hospital stay following
surgery was 9days (7–66 days). On exploration, 5 of the 6
large-bowel injuries were associated with posterior uterine
wall perforation, whereas 3 of the 5 small-bowel injuries
were associated with anterior wall or uterine fundus
perforation (Table 3). In 2 patients in whom uterine fundus
perforation occurred before the 12th week of pregnancy, the
gut (the small bowel in one patient and the rectosigmoid in
the other) had herniated through the tear into the
uterocervix and the bowel had undergone ischemic necrosis.
In the 3 patients with jejunal injury associated with colonic
perforation, the primary closure of the jejunal perforation
led to anastomotic leak. Two of these patients had a difficult
postoperative recovery period in intensive care. The third
patient, an unmarried girl with a pregnancy duration less
than 12 weeks, had gangrene of the entire small bowel
beyond the transected proximal jejunum, for which massive
bowel resection with diversion was performed. The girl left
the hospital against medical advice for social and family
reasons and died. All colonic injuries were limited to the
pelvis whereas the ileal injuries were mostly in the distal half
(Table 2). Other postoperative complications are listed in
Table 4.
4. Discussion
Let alone the fact that abortion is an extremely sensitive
topic everywhere, it is perhaps unreasonable to expect
reliable data about abortion practices in a country such as
India where even vital registration—the recording of births,
deaths, and marriages—is far from complete and accurate
[2]. A study conducted by the Indian Council of Medical
Research in rural India revealed the incidence of legal
abortions to be 6.1 and illegal abortions to be 13.5 per 1000
pregnancies, accounting for 12% to 20% of maternal deaths
[3]. Although no reliable data are available for illegal
abortions, the total number of abortions per year in India is
estimated around 6million [3]. The present study confirms
the findings of earlier reports [4–8], that most illegal
abortions are conducted in the rural areas of developing
nations without adequate facilities, and by persons with no
knowledge of anatomy who operate with nonsterile instru-
ments. The striking demographic feature in the present study
was the history of repeated induced abortions in women with
a single female child (Table 1). This may be because of a
strong preference for sons, leading to prenatal sex determi-
R.S. Jhobta et al.
nation and female feticide. As many as 75% of all women in
India are aware not only of the methods of prenatal sex
determination and the availability of female feticide, but
also of the health hazards resulting from female feticide.
Yet, female feticide is widely practiced for socio-economic
reasons. A girl is considered a liability because a dowry must
be paid to marry her off, and after marriage, the expenses
incurred for her education are lost for her parental house-
hold [9]. The sudden spurt in cases in the last 2months of the
study may be due to a stricter implementation, regulation,
and prevention of misuse of the Prenatal Diagnostic
Techniques Act (Act 199410) in urban areas, which may
have prompted women to opt for the “clandestine modus
operandi” outside the city. In the present series, most
abortion-related bowel injuries occurred in the first trime-
ster, probably a reflection of the timing of pregnancy
termination. In addition, the likelihood of bowel perforation
is greater in unmarried girls because the nulliparous cervical
os is difficult to dilate [6]—although only one unmarried girl
underwent induced abortion in the present series, with
mutilating and then fatal bowel injury. The most commonly
injured regions of the bowel were the terminal ileum and the
pelvic colon because of their anatomic location and relative
fixity [10]. The site of bowel injury correlated with the site of
the uterine perforation (Table 3), but no correlation could be
established between bowel injury and pregnancy duration, in
agreement with the report by Imoedemhe et al. [6]. In
addition to intestinal perforations directly caused by an
instrument, there have been reports of bowel herniating
through uterine perforations and becoming necrotic from a
lack of blood supply [11], and this complication was seen in
two patients in this series. The overall management of
patients requires adequate preoperative fluid resuscitation,
a blood transfusion, and administration of broad-spectrum
antibiotics. As most of the patients were anemic and in sepsis
preoperatively–presenting late with gross purulent and/or
fecal contamination of the peritoneal cavity–resection of
the damaged bowel with exteriorization of bowel ends was
the preferred method (Table 2). Although the need for bowel
exteriorization, no matter how temporary, carries physical
and psychological morbidity, it increased the patients'
chances of survival (Table 4). To decrease morbidity and
mortality, adequate and appropriately timed surgery is of
extreme importance.
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