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Case Report

Gangrene of the Uterus: A Dreaded Complication of Unsafe Abortions

Rachna Agarwal, MD; Shalini Rajaram, MD; Neerja Goel, MD; Anshul Grover, MD; Mrinalini Kotru, MD

Gangrene of the uterus is one of the rare but dreaded complications resulting from unsafe abortion. The condition should be strongly suspected in a postabortal patient with a history of genital (abortal) manipulation by untrained operators. Intensive medical care—along with aggressive surgical intervention—remains the key to managing such cases. The prognosis despite the best of medical care is poor. The only solution is to improve abortion facilities worldwide to prevent the potential for maternal mortality.

The World Health Organization (WHO) estimates that about 46 million pregnancies end in induced abortions every year, and of these 19 million are performed under unsafe conditions.1 Conditions are even worse among women in underprivileged countries where more than 50% of abortions are unsafe. With the advent of legal, licensed abortion facilities and modern antibiotics, rates of abortion-related morbidity should be declining. However, in developing countries it is not uncommon to see patients with life-threatening systemic sepsis postabortion. These two cases of gangrene uterus from a developing country illustrate the occurrence of this dreaded complication following unsafe abortions.

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CASE 1

A 23-year-old woman, para one, presented with a complaint of abdominal pain for 2 days. She had a history of 3 months of amenorrhoea. The patient had undergone vaginal abortion (details obscure) 2 days previously, followed by a low-grade fever (102Å F) with progressively increasing pain and a foul-smelling vaginal discharge. There was no history of exces sive vaginal bleeding or bowel/bladder complaints.

On examination the patient was found to have normal blood pressure, but she was febrile and tachycardic. Findings from her chest and cardiovascular examinations were normal. Abdominal examination revealed board-like rigidity with rebound tenderness. There was no other organomegaly. Vaginal examination revealed localized heat with fullness in both fornices. There was significant cervical-motion tenderness, and the exact size of the uterus could not be determined. Purulent vaginal discharge was present. Serum chemistry results (including prothrombin time) were normal, as were radiographic findings for the chest and abdomen, with no gas under the diaphragm. There were no features indicating the presence of disseminated intravascular coagulation.

With a provisional diagnosis of septicemia following septic abortion with peritonitis, the patient underwent emergency exploratory laparotomy. Preoperatively she received intravenous (IV) broad-spectrum antibiotics. Foul-smelling, greenish fluid was observed in the abdominal cavity and covering the entire discolored pelvic peritoneum. The uterus was equal to approximately 10 weeksÍ gestation in size, markedly congested, and greyish-black, indicating gangrenous change. There was rupture of the uterine fundus, with fetal products encapsulated in blebs throughout. The patientÍs fallopian tubes and ovaries appeared to be normal. The uterine and ovarian pedicles were not thrombosed. Bowel exploration did not reveal any perforation. Given the extensive uterine involvement a total abdominal hysterectomy was performed. Histopathologic analysis confirmed the finding of gangrene of the uterus with extensive necrosis and bacterial colonization of the endometrium (Figures 1a, 1b). However, there were no signs suggestive of gas gangrene.

Postoperatively the patient received intensive medical support, but her condition followed a progressive, downhill course. Subsequently, she developed a high-grade fever, hypotension, and acute respiratory distress syndrome. The patient died on postoperative day 9.

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FIGURE 1. Microphotography showing widespread necrosis of endometrium (1a) extending into the myometrium (1b) (10X, hematoxylin and eosin stain) (Case 1). Courtesy of Rachna Agarwal, MD.

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CASE 2

An 18-year-old woman presented with a complaint of acute abdominal pain for 2 days following termination of a 2-month pregnancy performed by a local woman who served as an untrained midwife. The pain was acute in onset with increasing intensity, and localized to the lower abdomen. She gave a history of high-grade fever and a blood-stained, foul-smelling vaginal discharge for 2 days. She reported no bowel or bladder complaints.

On examination the patient was conscious and well oriented, but febrile (102Å F). Her pulse rate was 120 beats/min, and her blood pressure 100/60 mm Hg. Cardiovascular and respiratory findings were within normal limits. On examination the abdomen was soft, with marked suprapubic tenderness. Bowel sounds were present. Speculum examination of the vagina revealed a foul-smelling, blood-stained discharge. The cervix was deviated to the right, with marked uterine and cervical tenderness. The uterus was soft, retroverted, and equal to approximately 6 to 8 weeksÍ gestation in size. Cervical and uterine movements were painful.

The patientÍs hematologic findings revealed a hemoglobin value of 8 g/dL, with an elevated leukocyte count of 18,000/mm3. Abdominal radiography revealed no gas under the diaphragm. Ultrasonography showed a mixed, echogenic collection in the peritoneal cavity, suggesting uterine perforation at the fundus. With a presumptive diagnosis of postabortal perforation, the patient underwent emergency laparotomy.

Surgical findings included approximately 200 mL of intensely foul-smelling, dark-colored fluid in the peritoneal cavity. The uterus was soft in consistency, congested, and discolored, suggestive of gangrenous change. Both ovaries appeared to be normal. Subtotal hysterectomy was performed. On gross pathologic evaluation of the uterus, a foreign body consistent with a 2-X-4-cm tree twig was found in the cervix (Figures 2 and 3). Histopathologic analysis revealed infiltration of inflammatory cells in the endometrium and myometrium (Figure 4) with liquefactive necrosis of the myometrium confirming gangrenous uterine changes. The patient gradually recovered in intensive care. She was discharged in a healthy condition after 3 weeks of hospitalization.

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FIGURE 2. On a cut section of the uterus a foreign body suggestive of a tree twig (“abortion stick”), 2 X 4 cm, was found in the cervix (Case 2). Courtesy of Rachna Agarwal, MD.

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FIGURE 3. The “abortion stick” (Case 2). Courtesy of Rachna Agarwal, MD.

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FIGURE 4. Myometrium showing extensive areas of necrosis and infiltration of inflammatory cells (40X, hematoxylin and eosin stain) (Case 2). Courtesy of Rachna Agarwal, MD.

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DISCUSSION

The WHO defines unsafe abortion as ña procedure for termination of an unwanted pregnancy, either by persons lacking the necessary skills or in an environment lacking the minimal medical standards or both.î1 In developing countries like India, approximately 20,000 women die annually due to unsafe abortions, contributing to 17.6% of all maternal deaths.2 Gangrene of the uterus is one of the rare but most feared complications of unsafe abortion. A review of the literature has revealed numerous cases of gas gangrene following septic abortion.3-6

Both of the patients presented here developed gangrene of the uterus following unsafe abortions. These reports are unique, as neither featured histologic evidence of gas gangrene. The first patient had perforation of the uterus following unknown intervention by a dai (local midwife), resulting in infection of the retained products of conception. The second patient had infection following placement of a wooden ñabortion stickî in the cervical canal to induce termination of pregnancy. The abortion stick may have been a wooden or bamboo twig, or a piece of an irritant plant such as madar (calotropis) or chitra (plumbago zeylanica).7 These sticks are soaked in an irritant solution (eg, marking nut juice; paste from white arsenic, lead, or asafoetida), or may act by themselves as abortifacients.7

Following unsafe abortion the presence of dead, devitalized, retained products of conception predisposes to infection. In addition, the interventional agents introduced into the vagina in these cases may be the ultimate cause of the infections. Another possibility is that the normal genital flora (eg, Clostridium welchii) may overgrow and become pathogenic, leading to sepsis.8,9 Infection is initiated in necrotic tissues and spreads to the endometrium and myometrium. The infectious organisms flourish in the poorly oxygenated lymph channels, and the infection spreads quickly.9 Endometritis, myometritis, and peritonitis develop rapidly, and the patient becomes seriously ill. Gangrene of the uterus and resultant septicemia are characterized by peripheral circulatory collapse, acute hemolysis, jaundice, renal failure, and fatal outcomes.3,10

Women who undergo unsafe abortion in India are typically illiterate, of lower socioeconomic status, and sometimes of rural origin. They may be teenagers, women in their late 30 or early 40 years of age, or widows, and tend to approach unskilled practitioners in the late first or second trimester.1,2 Such abortions mainly take place under substandard conditions.

Septic abortion presents with chills, malaise, vomiting, diarrhea, abdominal pain, excessive bleeding, and/or a foul-smelling vaginal discharge (Table 1). In severe cases symptomatology is well developed by 48 hours.9,10 High-grade fever, hypotension, tachycardia, jaundice, and anuria may follow. Treatment of patients with suspected septic abortion starts with resuscitation as needed and high-dose IV antibiotics. Prompt, vigorous medical management is required, including correction of fluid and electrolyte imbalances and treatment of acute renal failure. The physician should also inquire about tetanus immunization and provide prophylaxis accordingly. Ultrasonographic evaluation should be performed to rule out retained products of conception and fluid in the pouch of Douglas. Abdominal radiography helps to detect gas under the diaphragm (indicating bowel perforation) or gas in the pelvis (indicating uterine gas gangrene).11 The presence of large, gram-positive bacilli in the discharge and ñport-wineî-colored serum/urine are suggestive of clostridial sepsis.12,13 Hyperbaric oxygen, penicillin (2 MU/d), and polyvalent serum have been recommended in suspected cases of uterine gas gangrene.14,15

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TABLE 1. Pathogenesis and Diagnosis of Gangrene Uterus

After appropriate medical management and stabilization of the patient exploratory laparotomy should be performed. Hysterotomy may be required to assess the extent of infection.10 If the infection is limited to the fetus and the endometrium, a conservative approach may be adopted.9 In cases of an unsalvageable uterus, hysterectomy and excision of clinically involved adnexae are required.9,13 Decker and Hall16 cited a case mortality of only 9.1% when immediate hysterectomy of an infected uterus was performed. However, despite the best medical and surgical management, the gangrenous uterus is often associated with a mortality rate of up to 70%.13

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CONCLUSION

These cases highlight how unsafe abortions can lead to hysterectomy in some young women and death in others. Reports in the literature emphasize the need to increase the availability of safe abortion facilities, especially in developing countries. Adequately equipping primary healthcare centers and private clinics can help to reach this goal. Recently, simple and safe abortion methods (eg, manual vacuum aspiration, mifepristone, misoprostol) have been introduced that are not anesthesia-dependent and are virtually nonsurgical. Education, motivation, and availability of facilities are the keys to significantly lowering abortion-related maternal morbidity and mortality. Equally important is education about family planning to curb unwanted pregnancies. Finally, rigid enforcement of legalized abortion in practice can do much to reduce the prevalence of illegal abortions and their sequelae.1

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Rachna Agarwal, MD, is lecturer; Shalini Rajaram, MD, is professor; Neerja Goel, MD, is professor; Anshul Grover, MD, is senior resident, Department of Obstetrics and Gynecology. Mrinalini Kotru, MD, is lecturer, Department of Pathology. All are at the Guru Teg Bahadur Hospital, University College of Medical Sciences, Shahdara, Delhi, India.

References

1. World Health Organization. Unsafe abortions: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2000. 4^th ed.
   http://www.who.int/reproductive-health/publications/unsafe_abortion_estimates_04/estimates.pdf. Published 2004. Accessed August 19, 2007.
2. Survey of causes of death (rural) India, 1991-95. New Delhi, India: Office of the Registrar General of India, Vital Statistics Division; 1998.
3. Godsick WH, Hermann HL, Jonas G, Lester F. Uterine gas gangrene; review with recent advances in therapy and report of three cases. Obstet Gynecol. 1954;3(4):408-415.
4. Roux JP. Self-induced abortion complicated by gangrene of the uterus and anuria. Proc R Soc Med. 1956; 49(2):90-92.
5. Jones RA. Gangrene of the uterus and its sequelae. S Afr Med J. 1973;47(29):1327-1330.
6. Nanda S, Sangwan K, Agarwal U. The ugly face of septic abortion. Eur J Obstet Gynecol Reprod Biol. 2002;105(1):71-72.
7. Parikh CK. Parikh’s Textbook of Medical Jurisprudence and Toxicology. New Delhi, India: CBS Publishers; 1990:472-3.
8. Rotheram EB Jr, Schick SF. Nonclostridial anaerobic bacteria in septic abortion. Am J Med. 1969;46(1):
   80-89.
9. Holtz F, Mauch EW. Gas gangrene of uterus: survival following hysterectomy. Obstet Gynecol. 1962;19:
   545-548.
10. Winshel AW, Nelson JH, Albert SN. Puerperal gas gangrene; report of a case. Obstet Gynecol. 1957;9(4):481-484.
11. Bennett MJ, Strasburg ER, Kottler RE. Radiological diagnosis of gas gangrene of the uterus. S Afr Med J 1973;47(42):2019-2020.
12. Eaton CJ, Peterson EP. Diagnosis and acute management of patients with advanced clostridial sepsis complicating abortion. Am J Obstet Gynecol. 1971;109(8): 1162-1166.
13. Smith LP, McLean AP, Maughan GB. Clostridium welchii septicotoxemia. A review and report of 3 cases. Am J Obstet Gynecol. 1971; 110(1):135-149.
14. Perrin LE, Ostergard DR, Mishell DR Jr. The use of hyperbaric oxygen in the treatment of clostridial septicemia complicating septic abortion. Report of a case. Am J Obstet Gynecol. 1970;106(5):
    666-668.
15. Bittner J, Racovit C, Crivda S, Ardeleanu J.Combined therapy in post-operative gas gangrene. J Med Microbiol. 1970;3(2):325-332.
16. Decker WH, Hall W. Treatment of abortions infected with Clostridium welchii. Am J Obstet Gynecol. 1966;95(3):394-399.

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