Criminal abortion is an artificial termination of pregnancy with the consent of a woman, performed in a manner and within a time frame for which criminal liability is provided. Complications of illegal abortion may be manifested by weakness, dizziness, impaired consciousness, mucopurulent and bloody vaginal discharge, abdominal pain, hyperthermia, increasing intoxication and multiple organ failure. Criminal abortion is diagnosed by vaginal examination in mirrors, bimanual palpation, ultrasound of the pelvic organs. Antibiotics, hemostatics, infusion therapy, and a wide range of surgical methods are used to treat complications.
ICD 10
O05 O06
General information
We are talking about criminal (illegal, illegal, criminal) abortion in cases when gestation is interrupted by a woman independently or with her consent by a person without an appropriate medical education. As a rule, such an intervention is performed outside medical institutions. Abortion is also considered criminal when it is performed by an obstetrician-gynecologist outside a specialized institution or without medical or social indications after 12 weeks of gestational age.
According to experts of the Guttmacher Institute (USA), who study the problems of abortion in the world, up to 20 million pregnancies are illegally interrupted every year, almost 70 thousand women die as a result of complications. The highest rates are recorded in developing countries. In the USA, criminal abortions account for 3% of all abortions, more than half of them are represented by the termination of teenage pregnancy.
Causes
The use of illegal methods of gestation termination by women is caused by social factors: educational and cultural level, belonging to a certain social group, society’s attitude to unwanted pregnancies, peculiarities of legal regulation. The most common causes of illegal abortions are:
- The desire to hide pregnancy. An attempt to terminate gestation outside the walls of a medical institution is more often made by adolescents who require parental consent to perform a medical abortion. Fear of publicity is a significant factor for women who have committed adultery or belong to a social group where an intolerant attitude towards extramarital conception is practiced.
- A missed opportunity to have an abortion. In the USA, late termination of gestation (from 12 to 22 weeks) is allowed if there are certain indications — medical (HIV, tuberculosis and other serious diseases) or social (death of her husband, more than 3 children, divorce). After a 22-week period, the fetus is considered a living person, so an abortion can be equated with murder.
- Prohibition of abortions. In a number of States, the decision on artificial termination of pregnancy is restricted by law or is considered unacceptable from a religious point of view. If it is impossible to get rid of an unwanted child during an “abortion tour” to neighboring countries, women try to terminate gestation on their own or with someone else’s help.
- Illiteracy. In some cases, pregnant women, fearing the consequences of an official abortion, decide to use “gentle” abortive techniques — thermal, physical effects, taking hormonal drugs or uterotonic agents. The effectiveness of such methods is extremely low, toxic effects on the woman and fetus are possible.
Pathogenesis
The mechanism of abortion depends on the method of performing a criminal abortion. Taking various medications (steroid anti-progestogenic agents, synthetic analogues of female sex hormones, uterotonic drugs) involves the death of the embryo, disruption of implantation processes, increased contraction of the uterine muscles with the expulsion of the fetus. The introduction of chemicals and various objects into the cervical canal and uterine cavity is aimed at stimulating miscarriage due to damage to the fetal egg. Criminal termination of gestation, in which special medical instruments are used, provides for the separation of the fetus with its membranes from the uterine wall.
With community-acquired administration of chemicals, plant parts, various objects and even special tools into the vagina and uterus, the requirements of asepsis and antiseptics are usually not met. As a result, the risk of microbial contamination of the mucous membranes increases significantly. The situation is aggravated by injury to the organ wall, accumulation of blood clots in the uterine cavity and destroyed remnants of the fetal egg, which are a good breeding ground for the development of pathogenic microorganisms. The endometrium is first involved in the infectious and inflammatory process, and then other uterine membranes, appendages, pelvic peritoneum. In the absence of adequate medical care, generalization of infection with the development of peritonitis and sepsis is possible.
Classification
When systematizing the forms of criminal termination of pregnancy, many factors are taken into account, from the timing of abortion to the methods and means used. This approach makes it possible to take into account possible medical risks as much as possible and to develop an optimal scheme of patient care. Specialists in the field of practical gynecology distinguish the following options for criminal abortions:
- By timing: early and late illegal abortions. Usually, the later a woman decides to get rid of a child, the more serious the complications and long-term consequences. In addition, abortion in the presence of a viable fetus can be regarded as murder and aggravate criminal responsibility.
- At the place of termination of pregnancy: abortions performed at home and in non-specialized medical institutions. Although termination of gestation is considered criminal in both cases, its conduct outside of a medical institution increases the likelihood of an unfavorable outcome and has more serious consequences.
- According to the executor of the abortion: self-termination of pregnancy by a woman, abortion performed by a non-medical, non-specialized specialist, obstetrician-gynecologist outside a specialized institution or without appropriate indications. Complications are likely in all cases, but abortions performed by non-specialists are the most dangerous.
- According to the method of abortion: medical, mechanical, “folk” methods. Hormonal drugs and uterotonics are used for medical abortions. In mechanical cases, catheterization of the uterine cavity with the filling of chemicals, vacuum aspiration, curettage, the introduction of sharp objects, physical effects (blows to the abdomen, lifting weights) is possible. “Folk” methods involve drinking decoctions, mustard baths, etc.
- By the nature of complications: with bleeding, infection, poisoning, embolism. Hemorrhages are a consequence of the delay of parts of the fetal egg, trauma, coagulopathy. Infected abortions are uncomplicated febrile (with localization of infection in the uterus), complicated febrile (with the spread of inflammation in the pelvis), septic.
Symptoms
Clinical manifestations of the pathological condition depend on the chosen method of illegal intervention. When taking hormonal drugs and drugs that stimulate the contraction of the myometrium, poisoning with nausea, vomiting, dizziness, headache is possible. In severe cases of overdose of toxic substances (quinine, ergot), the pressure rises or drops sharply, the heartbeat quickens, the woman feels interruptions in the work of the heart, there is deafness, confusion or loss of consciousness. Some patients develop copious incessant uterine bleeding against the background of a medical abortion.
With mechanical methods of criminal termination of gestation, massive uterine bleeding is most often observed with a rapid deterioration in general well-being and hemodynamic parameters, detected in 25-40% of women who have undergone an illegal abortion. The infection is indicated by increasing hyperthermia, increasing pain in the suprapubic region, mucopurulent vaginal discharge. Usually the patient’s condition is noticeably disturbed: weakness, fatigue, pallor, sweating, dizziness appear. With a pulmonary embolism, there is a sharp pain in the chest, shortness of breath, palpitations, fear of death.
Complications
The World Health Organization recognizes abortions, especially criminal ones, as the most serious problem of protecting women’s reproductive health in many States. From 13 to 60% of maternal mortality in different countries is caused by complications after illegal termination of gestation. In 80% of cases, the cause of death of a patient after a criminal abortion is sepsis, in 14% — bleeding, in 6% — peritonitis. With mechanical and chemical interventions, ruptures of the vagina and cervix, perforation of the uterine wall, urethra, bladder, rectum, loops of the large and small intestines, chemical burns of the mucous membranes, DIC syndrome are possible. On the background of bleeding and inflammatory processes (acute endometritis, salpingitis, adnexitis), infectious and toxic shock, renal liver failure may develop.
Since gestation is not always successfully interrupted in a criminal way, malformations may occur in a fetus exposed to toxic effects. Long-term consequences of complicated illegal abortions are chronic endometritis, adnexitis, endocervicitis, colpitis, cervical erosion, menstrual cycle disorders. Reproductive function often suffers – the risk of habitual miscarriage, ectopic gestation, premature birth, fetoplacental insufficiency, labor anomalies, placental increment and other obstetric complications significantly increases. Up to 40-80% of women who have undergone a criminal abortion remain infertile. Some patients develop post-abortion stress syndrome with depression, suicidal thoughts, guilt, sexual disorders, and substance use.
Diagnostics
The objectives of the diagnostic search in criminal abortions are to establish the fact of termination of pregnancy, an objective assessment of the state of the reproductive organs and the completeness of the expulsion of the fetus, the identification of possible damage. Even if the patient does not report an illegal abortion, a thorough examination allows you to identify its signs. The examination usually includes such methods as:
- Examination on the chair. During gynecological examination, there is an increase in the uterus, which has a soft consistency. Blood clots may be present in the vagina. Discharge from the neck is often detected. With bimanual palpation, soreness in the lower abdomen is determined. A hematoma after perforation is represented by a volumetric formation in the area of appendages, infiltration of the vaginal arches is characteristic of parametritis.
- Ultrasound of the pelvic organs. During an ultrasound examination, a fetal egg or parts of it may be detected in the uterus. It is possible to expand the uterine cavity due to the accumulation of blood. For more accurate visualization, transabdominal ultrasound is recommended to be supplemented with transvaginal examination. The method also allows you to assess the thickness and condition of the uterine wall, the spread of the inflammatory process to other organs.
Women with probable criminal termination of gestation are prescribed a general blood test, which often determines a decrease in the number of red blood cells, leukocytosis, increased ESR, as well as a general urine test. Specialists evaluate the characteristics of hemostasis (fibrinogen, prothrombin, APTT), examine the biochemical parameters of blood (AlT, AsT, total protein, glucose, total bilirubin, urea, creatinine), perform an ECG. If there is a reasonable suspicion of extragenital complications, ultrasound of the abdominal cavity organs, lung radiography, CT of the chest organs are performed. Illegal abortion is differentiated with the threat of termination of gestation, ectopic pregnancy, acute appendicitis, cystic drift, placental polyp. According to the indications, consultations of an infectious disease specialist, urologist, surgeon, nephrologist, hematologist, angiosurgeon are prescribed.
Treatment
In case of illegal termination of pregnancy, the patient is subject to emergency hospitalization. The purpose of the doctor’s actions is to eliminate the complications that have arisen, therapeutic measures are carried out taking into account the protocols for the treatment of uterine and intra-abdominal bleeding, inflammatory diseases of the reproductive organs, septic conditions, peritonitis, embolism. Conservative therapy of complications of criminal abortion involves the appointment of the following groups of medications:
- Antibiotics. Antibacterial therapy is aimed at combating pathogens of infectious and inflammatory processes. The selection of drugs, if possible, is carried out taking into account the sensitivity of microorganisms. Parenteral methods of drug administration in combination with prevention of dysbiosis are preferred.
- Hemostatics. Hemostatic drugs are indicated for ongoing hemorrhages associated with a violation of the blood clotting system. They are used both locally and systematically. Coagulants acting on different parts of the hemostasis system increase blood clotting and allow you to stop bleeding.
- Infusion solutions. The use of colloidal and crystalloid compositions ensures the restoration of the volume of circulating blood and its rheological characteristics, nutrition and rapid detoxification of the body, which is especially important for drug poisoning. In particularly severe consequences of abortion, hemosorption and hemodialysis are performed.
Intensive symptomatic therapy with the appointment of cardiotonic drugs, hepatoprotectors, diuretics, antioxidants, antiplatelet agents and other medications is aimed at correcting multiple organ disorders characteristic of criminal termination of pregnancy. If conservative treatment is ineffective, the operation is recommended for the patient.
The volume of surgical interventions is determined by the revealed pathology. Necrotized remains of the endometrium, fetus and its membranes are evacuated from the uterine cavity using curettage or vacuum aspiration, a qualitative revision of the uterus is provided. In the presence of tubovarial inflammatory formations, tubectomy, tubovarektomy is performed. Depending on the degree of organ damage and the presence of infectious complications, patients with uterine wall perforation are recommended to suture the perforation or hysterectomy. The detection of signs of pelvioperitonitis and diffuse peritonitis is the basis for laparoscopic or laparotomic intervention with sanitation, revision, drainage of the abdominal cavity, and often removal of the uterus with appendages. In difficult cases, resection of the omentum, intestines is performed, intestinal stoma, cystostoma is removed.
Prognosis and prevention
The later a woman with complications caused by a criminal abortion seeks medical help, the worse the prognosis. The occurrence of severe disorders and the death of the patient are most likely with mechanical variants of gestation interruption with penetration into the uterine cavity. Preventive measures involve active promotion of contraception from school, informing women from risk groups about the danger of criminal interventions, legislative regulation of childbearing issues taking into account the interests of women, providing affordable obstetric and gynecological care to patients with unwanted pregnancies.
