Abstract
Injuries to the bowel are seldom reported. Yet these pose serious problems associated with uterine perforation during deliveries that take place outside of hospitals. This is also true for abortions that are performed illegally in developing countries by persons without any medical training. This case study is about a 20 years old girl who lost her life following an unsafe delivery at home. To avoid morbidity and mortality associated with unsafe deliveries, it is necessary to understand the scope of this problem and the factors related to it: governments, nongovernmental organizations, religious groups and women groups.
Introduction
Bowel injury is uncommonly reported yet is a serious complication particularly when associated with uterine perforation either during home delivery or therapeutic abortion. Such interventions in low- and middle-income countries are often performed by people without proper medical training and using improvised instruments. If complications arise, both the patient and her family rarely reach help owing to a multitude of factors. We present one such disastrous case of near-total disembowelment after receiving informed written consent from the patient and parents for publication of data including photographs.
Case report
The gruesome photograph shown (Figure 1) is of a young girl who was brought to our institute as an emergency with her bowel eviscerated in its entirety. At admission, she was in shock with a tachycardia of 120/min, blood pressure 70/40 mmHg, respiratory rate 20/min, pallor and a fever of 37.8℃. Vigorous resuscitation was commenced, correcting an anaemia (Hb 4 g/dl) with 3 units of whole blood, and broad spectrum antibiotics covering aerobes and anaerobes were infused. Laparotomy was commenced when her general condition improved and she started passing urine. On microscopy, this demonstrated the presence of copious pus cells. It was found that the entire small bowel, transected at the duodeno-jejunal junction, and almost all the large bowel the recto-sigmoid junction, was protruding from the vagina, having prolapsed through a large rent in the uterus involving almost the whole body and fundus. Astonishingly, the mesentery was not found attached to the bowel at all. The devitalised gut from duodenojejunal to rectosigmoid junction was removed, vessels in the lacerated mesentery ligated, the wide open uterus was closed after freshening its margins and the abdomen closed with tube duodenostomy drainage.
Young girl with complete gut outside through the vagina.
All attempts to gain a coherent history from various relatives of events leading to the disembowelment yielded no results. The only fact that it was possible to establish was that a home delivery had been attempted by an unlicensed practitioner delivering a healthy full-term baby. It was evident, by questioning the patient’s mother, that some instrumentation had been used during delivery resulting in prolapse of intestinal loops through the vagina. Considering these structures to be placental tissue, he continued pulling them out in an attempt to complete delivery.
Postoperatively, the patient received parenteral hyperalimentation, but it was explained that without the option of an intestinal transplantation, this would be needed in the long term. After 3 weeks, she left against medical advice and has been lost to follow-up despite all efforts to trace her. We informed the local police about the incident.
Discussion
This case once again highlights the horrors of medical ignorance faced by patients in rural India where the medical scenario still remains archaic and unregulated practitioners practise without inhibition. Cases of transvaginal evisceration has been described in literature following dilatation and curettage, hysterectomy, vault biopsy and post-coital fornix perforation.1–4 Unsafe abortions performed by inexperienced caregivers is a common cause of such injuries in developing countries but such uncommon events have also been described in the developed world in expert hands, even at tertiary care centres. 2
Lack of available public facilities, poor socioeconomic conditions and illiteracy, associated with social and religious stigma, provide opportunities for unqualified and untrained persons to offer improvised services, often in secrecy and in ill-equipped settings.
In order to avoid morbidity and mortality associated with unsafe deliveries and abortions, it is desperately necessary to understand the scope of the problem and the related factors. Publishing every case on the subject for construction of more precise diagnostic and therapeutic algorithm has been recommended. 2 Awareness as well as a high index of suspicion among gynaecologists and caregivers is of paramount importance for the early diagnosis of such life-threatening conditions necessitating prompt surgical intervention, and simultaneously physicians should be aware that initial patient history may be inaccurate or misleading if taken in the presence of family or a partner given the sensitive nature of the injury.1,3,4
A crackdown on unauthorised personnel involved in the delivery will not prove successful without provision of easy accessibility at all times to adequate, affordable and appropriate healthcare.
Education programmes may go some way in preventing such tragic loss of young life. It is high time, however, that a consortium of government experts, in partnership with non-governmental organisations, religious groups and women groups, should embark on efforts to provide essential obstetric and surgical care for the millions in low- and middle-income countries who will die without it.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.