1. Dr. Namrata Gupta
Prof. Dr. Chanda Karki
Gynaecology/obstretics dept.
2. Ms. Limbu, 25 year old, unmarried girl presented
in emergency dept. on 17th chaitra 066 at 1: 30 a.m
c/o-heavy menstrual bleeding- 2 days
headache and dizziness
On eliciting she gave h/o amenorrhea for 2 months
Patient also gave h/o previous irregular menses and
heavy bleeding during menstruation.
No h/o pain abdomen, use of any medication or any
bleeding disorder.
No h/o any contact or any other medical illness
(patient was reluctant in giving proper history)
3. All basic investigations were sent(including Urine
pregnany test)
Inj Tranexemic acid 500 mg IV STAT was given.
IV Fluids were started.
4. GC- Ill- looking
Pallor-+++(patient looked paper white)
Vitals: T- 100°F, Pulse- 102/min,
B.P- 90/60mmhg
S/E:
P/A- Soft, non- tender, BS+ve
P/S- active bleeding++
- cervical os-open, cervical laceration,
P/V- uterus- 12weeks size(approx), anteverted,
cervical os open, bleeding+ with passage of clots
5. Hb%- 6.2 gm%
Blood group: AB+ve
Total count- 22,100/mm3 (N- 84%, L- 15%)
Platelets: 1,30,000/mm3
Urine Pregnancy Test: POSITIVE
All other investigations were within normal range
6. Patient admitted by 2:00 a.m
Patient immediately shifted to OT
Whole blood transfusion was started
Examination under anesthesia(EUA) and Suction &
evacuation(S&E) done at around 2:30 a.m
7. Operative findings:
P/V- Cervix lacerated
Os open
Bleeding ++
Plenty of Product of conception obtained and sent
for HPE.
9. Patient monitored closely .
IV fuilds and IV antibioitics (Megapen, Metron, and
gentamycin) given.
IV Pint of whole blood transfused on POD and
POD1
Post transfusion Hb%- 11.3 gm%
Patient became afebrile on POD2 , blood pressure
maintained and was discharged on POD4 .
10. Patient’s clinical examination and operative
finding gave picture of unintended pregnancy
which had been intervened by unsafe methods to
induce abortion
But patient denied any such history till last day of
her hospital stay.
11. The WHO defines an unsafe abortion as-
"any procedure to terminate an unintended
pregnancy done either by people lacking the
necessary skills or in an environment that does not
conform to minimal medical standards, or both."
12. The most common abortion complications are
haemorrhage, shock, sepsis and intra-
abdominal injury.
Left untreated, each can lead to death
Medium and long-term complications range from
reproductive tract infections (RTI)- (20-30%) &
pelvic inflammatory disease (PID)-(20-40% )to
chronic pelvic pain and infertility.
Late complications include increased risk of
ectopic pregnancy, miscarriage or premature
delivery in subsequent pregnancies.
13. Each yr 75 million of women world-wide
experience unwanted pregnancy
46 million women have induced abortions
Nearly 20 million of these are estimated to be
unsafe.
13% of total maternal death occur due to unsafe
abortion.
"WHO: Unsafe Abortion - The Preventable Pandemic".
14. The WHO reports that in developed regions, nearly all
abortions (92%) are safe, whereas in developing
countries, more than half (55%) are unsafe.
16. Background
Abortion law was liberalised in Nepal in the month of
Chaitra 2058 (March 2002) after many years of
intensive research and advocacy.
The law received royal Seal in September 2002.
However, there was long delay of 15 months before
the procedural order was approved on December 25,
2003.
Nepal began providing comprehensive abortion care
(CAC) services in 2004
17. 245 sites listed for providing services
704 Providers (doctors/Nurses) trained as a
service providers
Services expanded to 75 districts.
Within three years time frame around 229,583
women were reported receiving safe and legal
abortion services (with around 90% of
contraceptive acceptance rate)
18.
19. LISTED PROVIDERS LOGO LISTED SITES
Listing Certificates, Cost of services and logo
should be hung in public place
20. According to the new law, only listed (trained)
doctors or health workers can provide safe abortion
services at listed (approved) health facilities, under
the following conditions:
Within the first 12 weeks of pregnancy for any woman
on her request. The permission of husband or guardian is
not required for women above 16 years of age
Within the first 18 weeks of pregnancy in cases of rape
and incest
At any time if the pregnancy poses danger to the life or
physical or mental health of the pregnant woman or the
foetus is seriously deformed and it is recommended by a
doctor.
21. Abortion is not allowed under coercion
Sex selective abortion is not allowed
Only listed Physicians/Health Workers
registered in their respective councils are
authorised
Only listed health institutions are authorised
27. Lack of knowledge about the abortion law.
Lack of knowledge of approved CAC centres
Inadequate access to safe and legal abortion
services
Low economic status, abortion fee,
Early marriage and child bearing
Low decision making power of women on
abortion and poor supportive environment
28. While unsafe abortion is one of the most common
causes of maternal deaths,
it is also the most easily preventable through the
provision of, and access to, safe abortion services
and care.
29. SAS/CAC service has become accessible and
affordable to Nepalese women even at peripheral
level.
CAC service has minimal complication and also
gives the opportunity for contraception.
Demographic and Health Survey, Nepal 2006
show a steady decline in the Maternal Mortality
Ratio (MMR) from 539 in 1996 to 281 in 2006.
Legalization of abortion and provision of safe and
legal abortion service may be one of the factors
that may have contributed to this decline.