Annotation: Iron Deficiency Anaemia in Pregnancy and its Management

Prof. Khalida Adeeb Khanum Akhtar

I agree with the author of the above mentioned case, that “Unsafe abortions” continue in huge numbers in our country, despite many efforts to curtail them. The above article being just a case report, the incidence and other parameters of unsafe Abortion in the author`s institution have not been reported.
However I presume that it will be of interest to refer to a case series,¹ that I had studied in Holy Family Hospital(HFH), Rawalpindi, way back in 1970s and early 80s, which had shown that out of 2678 total cases of abortions, those of septic induced abortion (SIA) as called then, were 244. Eighty percent of the latter belonged to lower socio economic back ground. They were mostly young with ages ranging from 17-45 years, parity 0-12, last child birth 4 months to 12 years, with majority of the women being otherwise healthy, but 22% which poor general health.
Furthermore in the preceding case discussion, it has not been indicated as to who if at all known, was the person performing the uncalled for, repeated trans vaginal procedures on the victimized  patient, as very often the identity of such people is not disclosed.  The preceding case discussion mentions, that most abortions are done by Dais and LHVS, referring to two Indian studies. But in my study referred to here in the cases in whom it was confessed, 36% were Dais and LHVS, 22% were nurses while, mind you please 28% were so called doctors! In 14% of the cases the patients themselves had attempted abortion. Amazingly enough, all abortionists were however women.
On the other hand the modes of interference found in the series were feathers, sticks, hooks and hair pins, though in some cases actual instruments were used, in addition to doctors by and large by the nurses. Chemical soaked swabs were also found in the vagina of some patients or history of their use was narrated.
Gut injuries were found in 3 out of 244 cases of SIA, which is very low, when compared to the series from Khyber Teaching Hospital, Peshawar referred to by the author of the above case report, most probably because HFH, Rawalpindi had a private set up in large proportion of the earlier part of my study, in context.
Septic shock seriously complicated 20% of the cases of my series and 5% of 24 cases died.
Coming to the crux of the matter it is noteworthy that from among 3 cases of gut injury in my series one was brought to HFH, Rawalpindi in a state of Septic shock, way back in 1982, conscious but hardly responding. Her abdomen was distended with crackling gas and gangrenous gut was extruding out of her vagina, in shreads. She, the unfortunate lady, para 6 had so called evacuation for termination of 11 weeks unwanted pregnancy, by a nurse (in a back street, unhealthy and unsafe set up) who must have recognized the gut coming out with the instruments she used and thereby kept the poor patient for three days in that shabby hut, she had got constructed for financial lust, grabbing money from poor desperate women. She kept giving moot antibiotics to the patients, without informing the relatives of the patient, for fear of litigation or monitory loss. It was only when the patients became moribund that she was released from that imprisonment and the relatives brought her to the hospital. I still remember her vividly, listless and lying on bed 6, counting from the nursing station, in gynae ward of the hospital. Alas despite all efforts she could not be saved! Such is the peril of these cases. Imagine the plight of her six children left behind.
This menace of hidden, unsafe, un hygienic abortions continues, more so in the countries where abortion is not or cannot be legalized, specially in under privileged societies, among poorer women, with lack of reach to contraceptives or the use of latter is not permitted by the husbands or the mother-in-laws!
The suggestions, made for curtailment of such disorders by the author of the preceding case report, are indeed valuable. I would however like to stress upon multicenter appropriate studies on cases of unsafe abortion for deduction of concrete evidence. Thereafter I would urge speedy formulation of our National, robust, evidence based guidelines for the management of abortion(s). They I understand are already in pipeline, under the able guidance of the present president of the Society of Obstetricians and Gynaecologists of Pakistan, Prof Lubna Hassan. Until then I would like to mention some axioms of management of such cases.
Axioms of case Management of cases of Unsafe Abortion: Immediate
These are invariably in operation in the tertiary care centers, but which need to be applied to all health facilities, where victims of unsafe abortion go. They are:-

• Preplanned treatment schedules for immediate implementation by the gynaecological and nursing teams.
• Pains taking history (from the relatives, if the patient herself is unable to narrate it), with all out efforts to identify the person involved and the place where such activities are carried out. There I would like to stress that the people who carry out unsafe abortions must be encouraged to come forwards and accompany the patients to the hospitals; rather than being shunned off and scared. Hoping that they will learn some better modalities.
• Correction of hydro-haemo-electrolyte state of the patient, immediately and its management, without any loss of time.
• Meticulous examination of the patient to find out the type of abortion (complete, incomplete or yet threatened or intact), as well as the extent of damage done by the abortionist.
• Evaluation of functional status of essential organs and monitoring of their parameters (Vitals).
• Ultrasound (and at times Radiological) assistance for presence of foreign bodies or gas in the pelvis or the abdomen.
• Pick up of ‘High Risk’ cases for ‘intensive care’.
• Appropriate collection of bacteriological specimens, from infected sites.
• Fast institution of effective antibiotics.
• High index of suspicion, detection and management of coaugulatory disturbances.
• After adequate antibiotic cover, early and careful evacuation of the uterus, where required, with more extensive surgical intervention if and when indicated.
• Strict follow up of cases, when possible.

Axioms of Management of cases of Unsafe Abortion: Long Term

• Attainment and maintenance of general health of the patient.
• Strict advice for Family planning (in presence of the husband and mother in law, if possible) for future spacing or prevention of further pregnancies, in multiparas, whose genital system remained intact after the havoc of induced abortion.
• Evaluation for future fertility status, if the patient is nulliparas or of low parity i.e. if her genital system did not have to be sacrificed during treatment for a complicated unsafe abortion.
• Last but not the least is the matter of specific nutritional status of patients like the preceding case report, in whom there was hardly any small intestine left behind. Though end to end anastomosis was possible. It is important to mention here, that however much the operating gynaecologists are trained, it is better to have general surgeons present too for comprehension and sharing of responsibilities in the event of medico-legal situations. In addition to which it is imperative to prevent and monitor such patients for gross malnutritions as discussed in an earlier issue of this journal,² with reference to ill effects of drastic reduction of calories but which could well be applied to the afore mentioned case, aslo.

References

1. Akhtar KAK. Induced Septic Abortion. Journal of Obstetrics and gynaecology of Pakistan 1985;1(1):33-38.
2. Akhtar KAK. Annotation: Life Style change. JSOGP 2011;1(2):121.