Binoy Krishna Golder¹, Mohuya Mondal², Tarek Hasan³, Mohammad Shariful Hasan⁴, Mst. Munira Akter Khanam⁵

1. Dr. Binoy Krishna Golder, Assistant professor (Gynae), Patuakhali Medical College, Patuakhali, Bangladesh.

2. Dr. Mohuya Mondal, Medical Officer, Upazila Health Complex, Gazaria, Munshigonj, Bangladesh.

3. Dr. Tarek Hasan, Junior Consultant (surgery), Borguna Sadar Hospital, Borguna, Bangladesh.

4. Dr. Mohammad Shariful Hasan, Medical Officer, dept. of Paed. Gastroenterology&Nutrition, BSMMU, Dhaka.

5. Dr. Mst. Munira Akter Khanam, Assistant Surgeon, Badarpur Union Health & Family Welfare Center, Sadar, Patuakhali.

Correspondace: Dr. Binoy Krishna Golder, Assistant professor (Gynae), Patuakhali Medical College, Patuakhali, Bangladesh. Mobile Number: +8801712247616, E-mail: [email protected]

ABSTRACT

Pregnancy usually held within uterine cavity in fully developed endometrium. Presence of foreign body, large polyp, intrauterine adhesion may impair implantation. Pregnancy associated with parts of small intestine within uterine cavity and continuation of pregnancy up to full term is very difficult and complex process. To our knowledge this is the first case reported in the literature. It was diagnosed incidentally during the process of emergency cesarean section. The patient added history of trial of induced abortion at 8 weeks period by unskilled practitioner, which was unsuccessful. Emergency cesarean section was done due to fetal and maternal distress. After delivery of the baby parts of small intestine had found entered through a small fundal opening into the uterine cavity. Adhesion of the intestine in the uterine cavity at level of internal os and it was buried deeply in the myometrium. Separation of the intestine, repair of myometrium and control of post-partum haemorrhage was challenging.

Keywords: Pregnancy associated small intestine, Intestine and gravid uterus.

INTRODUCTION

Perforation of uterus is life threatening condition to a woman. Usually this perforation is observed in case of induced abortion. Induced abortion is an essential component of comprehensive reproductive healthcare.  An estimated 56 million abortions are undertaken worldwide¹ and, in Britain one in three women will terminate a pregnancy². Worldwide an estimated 6.9 million women are treated for complications of unsafe abortion each year and up to 40,000 die³. With dilatation and curettage perforation occurs 2-3 per 1000 procedures. A history of two or more cesarean section deliveries is the strongest predictor of a major complication with dilatation and evacuations⁴. Continuation of pregnancy occurs in fewer than 1 in 1000 procedures performed at 12 weeks gestation or less but higher with uterine anomalies, multiparity,

very early gestational age or when performedby a less experienced surgeon.

 Perforation of uterus and injury to small gut may cause active bleeding, haemorrhagic instability, peritonitis, acute abdomen. Laparotomy or laparoscopy is the ultimate management. Intestinal injury involving serous or muscular layer with intact mucosa can occur. Traction of intestine with sponge holding forceps through wound of perforated uterus, may cause difficulty to return back even can cause strangulation of the folded intestine. Abrasion on serous surface of trapped small gut may help to adherent on raw uterine musculature. Healthy intestine may not be adherent with muscles at fundal opening. So continuation of peristaltic function through trapped intestine and also growth of pregnant sac simultaneously in the uterine cavity is possible.

CASE REPORT

The patient age of 35 years, height 150 cm, weight 49 kg, para 4, gravida 5, age of last child 10 years; admitted through Emergengy department in labour ward on 06/01/2021 at her 36^th weeks of pregnancy; with the complaints of per vaginal watery discharge for 2 days and history of continuation of pregnancy following induced abortion at her 12 weeks of pregnancy.

Quick examination of the patient was done. She was mildly anaemic, anxious looking, malnurished, mildly dehydrate and blood pressure normal, fundal height was 34 weeks size and absent liquor, cervix was 1.5cm dilated. Fetal distress was diagnosed.

 Emergency cesarean section had done; a healthy female baby 2.5 kg with average for gestational age found. After delivery of placenta, uterus exterior done. Parts of small intestine with mesentery had entered through a circular hole at the uterine fundus into the cavity. Intestine found deeply implanted within myometrium at the posterior wall at level of histological internal os. Intestine was separated cautiously keeping intact by cutting adjoining myometrium. Uterus was closed as usual. There was a clean healthy circular wound about 3cm in diameter and closed by continuous suture.

 Surgeon examined the intestine and other structures, all layers of intestine was intact. Patient was kept on intravenous saline and parenteral antibiotics for 3 days without any oral medication.

DISCUSSION

Although some planned pregnancies end in abortion, most women who have abortions did not intended to become pregnant. In the third National Survey of Sexual Attitudes and Lifestyles, 57% of unplanned pregnancies ended in abortion compared with 33% categorized as ambivalent and 10% as planned⁵.Unplanned pregnancy results from failures of contraception in some cases, but many occur because no contraception was used or because the method was used inconsistently or incorrectly⁶

 Women of low socioeconomic family with late reproductive age and high parity usually did not use contraception properly, many of them become pregnant. May hide to family members and unsafe abortion done and suffers from various complications, even death. Perforation of uterus and excessive haemorrhage, injury to intestine is common.    When mishap happen both patient and service provider tries to hide family members and suffer various complications. In cases of uterine fundal perforation, sudden stoppage bleeding by pressure effect of impacted   intestine is possible. Abrasion of intestinal serous layer and adherent with rough myometrial surface is also possible and held in this case.

 Proper identification of pathology, dissection from uterine myometrium, observation of intestinal viability and integrity and prevention of intestinal obstruction is vital.

CONCLUSION

Proper practice of contraception up to menopause should be practiced perfectly. In case of such complicated pregnancy management with skill hands can prevent different types of mishap.

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