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The case of a fatal abortion and the need for discussion among medical, legal communities

  • Ethical, religious, and political factors hinder prevention of maternal deaths, note academics 

BY Ruwan Laknath Jayakody 

Even though serious complications result from illegal abortions, causing both maternal morbidity and mortality, since reducing such has proven a challenge due to ethical, religious and political factors taking precedence over health related aspects, academics in the field of forensic medicine called on the medical and legal communities to initiate a discussion to reduce the number of maternal deaths resulting from illegal abortions. 

This clarion call was issued in a research article based on a case study on “A maternal death due to an illegal abortion – A case report” which was authored by W.N.S. Perera and P. Paranitharan (attached to the Kelaniya University’s Medical Faculty’s Forensic Medicine Department) and published in the Sri Lanka Journal of Forensic Medicine, Science, and Law 2 (1) in November 2011. 

An unwanted pregnancy, both J. Villarreal’s “Commentary on unwanted pregnancy, induced abortion, and professional ethics: A concerned physician’s point of view” and F.T. Sai and J. Nassim’s “The need for a reproductive health approach” noted, places a woman at additional risk if she seeks an abortion in a context where safe services for such are not often available. This risk, Perera and Paranitharan noted, varies from morbidity in the form of infertility to mortality. 

  1. Mahler’s pointed out in “The safe motherhood initiative: A call to action” that the World Health Organisation estimates that 25-50% of the 500,000 maternal deaths that occur every year result from illegal abortion with the majority of such taking place in underdeveloped countries. Furthermore, both L.S. Liskin’s “Complications of abortion in developing countries” and P.G. Stubblefield and D.A. Grimes’s “Septic (a potentially life threatening condition that occurs when the body’s response to an infection damages its own tissues where when the infection fighting processes turn on the body, they cause organs to function poorly and abnormally and may progress to septic shock) abortion” pointed out preventable morbidity and mortality from septic abortion. 

Local case 

A 39-year-old female who was living together with her male partner had missed her period. Pregnancy was subsequently confirmed. She had then gone to a “place” for an “abortion” where the “abortionist” had inserted a tube into her vagina and had performed a procedure involving suction. After coming home however, she had experienced severe vaginal bleeding along with chills. On the second day, she was admitted to a hospital with fever, abdominal pain, heavy vaginal bleeding and hypotension (low blood pressure). On the third day, the evacuation of the products retained from the conception and a laparotomy (involves making a surgical incision into the abdominal cavity) was performed as bowel perforation was suspected. 

Subsequent to the surgery, she suffered cardiac arrest and was then ventilated. She also had persistent hypotension, elevated liver enzymes, deteriorating renal functions, coagulation related defects and a tendency to bleed. On the fourth day, she had died while in the intensive care unit despite vigorous attempts at resuscitation. 

Post-mortem examination 

At the autopsy, the deceased was pale. There was haemorrhage (bleeding) into the venipuncture sites (the process of obtaining intravenous access where a hollow needle is inserted through the skin and into a superficial vein), and confluent (flowing together or merging), petechial (tiny spots of bleeding under the skin or in the mucous membranes) haemorrhages on the body. There were no injuries to the genitalia. The surgical incision on the abdomen was intact and not infected. There was subarachnoid (the area between the brain and the skull) haemorrhage. 

The lungs were heavily congested. The bowels were dusky. The omentum (a large flat adipose [fat] tissue layer nestling on the surface of the intra peritoneal [the tissue that lines the abdominal wall and covers most of the abdominal organs] organs) was soft. The liver had a nutmeg like appearance. The kidneys were reddish and swollen. The spleen was soft. The uterus was enlarged, and the uterine tubes and ovaries showed haemorrhagic patches with bluish discolouration. There were foul smelling blood clots in the irregular uterine cavity. The uterine wall was devoid of perforations. 

Pseudomonas (infections caused by a bacteria called Pseudomonas) infection was positive from the retained products of the conception. The histology (microscopic anatomy of biological tissues) revealed features of organ failure, necrotic material with remaining foetal tissue in the uterus and neutrophil (a type of white blood cell that kill and digest bacteria and fungi in order to help the body fight infections and heal wounds) infiltration into the myometrium (the middle layer of the uterine wall). The cause of death was ascertained as complications of a septic abortion. 

As Perera and Paranitharan observed, mortality and morbidity from septic abortions are frequent in countries where induced abortions are illegal (in Sri Lanka, induced abortion can only be legally done to save the life of the mother) or inaccessible.

The duo explained that the death in the instant case was due to the contribution of two major factors which led to the development of complications from the septic abortion. The two factors were the presence of retained products of the conception following the illegal abortion and an infection being introduced into the uterus at the time of the abortion. 

Both “Health and economic consequences of septic induced abortion” by J.C. Konje, K.A. Obisesan and O.A. Ladipo, and “Causes of maternal mortality in rural Bangladesh” by V. Fauveau, M.A. Koenig, J. Chakraborty and A.I. Chowdhury emphasised that abortion-related deaths result mainly from sepsis. “The infection usually begins as endometritis (an inflammation or irritation of the lining of the uterus) and involves the endometrium (the uterus) and any retained products of the conception. 

If not treated, the infection may spread further into the myometrium and parametrium (the fat and connective tissue that surrounds the uterus). The patient may develop bacteremia (the presence of viable bacteria in the circulating blood) and sepsis (the body’s extreme response to an infection) at any stage of a septic abortion. In this case, the presence of highly virulent pseudomonas infection in the uterus can act as a focus of infection releasing endotoxins (complex lipopolysaccharides [large molecules consisting of a lipid and a polysaccharide] which form an inherent fraction of the outer cell wall of all gram negative bacteria and are responsible for the organisation and stability of the cell wall) and exotoxins (a group of soluble proteins that are secreted by the bacterium which enter host cells, and catalyse the covalent [chemical bonds that are formed and are biologically important] modification of a host cell component/s to alter the host cell physiology).

This will cause a systemic inflammatory response as a reaction to the bacterial infection. The further release of vasoactive substances (an endogenous agent or pharmaceutical drug that has the effect of either increasing or decreasing the blood pressure and/or heart rate through its vascular activity) is associated with organ dysfunction, hypoperfusion (a reduced amount of blood flow) or hypotension, metabolic abnormalities, and microcirculatory failure, leading to septic shock.

In this case, there was evidence of bleeding into tissues, subarachnoid haemorrhage due to coagulation and bleeding defects. Macroscopic and microscopic appearances of the organs as well as clinical investigations suggested organ dysfunctions and metabolic defects. Combined complications of sepsis had caused the death of this person,” Perera and Paranitharan further explained.

In conclusion, Stubblefield and Grimes pointed out that the primary method of the prevention of septic abortion is the provision of effective and acceptable contraception, the provision of safe and legal abortion services in the case of contraceptive failure and the appropriate medical management of the abortion thereafter.