Small bowel exteriorisation after uterine perforation from manual vacuum aspiration for abortion in a young cameroonian: a case report

Manual vacuum aspiration is an effective and safer surgical method of uterine evacuation for an abortion. Nonetheless, it can present some life-threatening complications like uterine perforations. In a uterine perforation the suction cannula is thought to be usually involved in the perforation and the resulting intraabdominal organ damage. We presented a case of a young muilti-parous Cameroonian woman who was underwent a manual vacuum aspiration for a first trimester incomplete abortion, and which was complicated by a fundal uterine perforation with exteriorisation of small bowels through the vagina.


Introduction
Abortion and its complications are serious problems in gynaecology.
Both spontaneous and induced abortion may have life threatening complications. Surgical management of abortions are known to have some serious complications especially with the use of uterine curettage [1]. With the advent of manual vacuum aspiration (MVA), lesser complications were reported and this method has proven its effectiveness and safety [2]. Despite this safety of the MVA, cases of life-threatening complications have been reported. We are presenting a case of small bowel exteriorisation after uterine perforation from manual vacuum aspiration for incomplete spontaneous abortion.

Patient and observation
A 24 year old G2 P1 011 was referred to the Bamenda Regional Hospital from a district hospital for the management of exteriorisation of bowel through the vagina. She was seen earlier that day for per vagina bleeding accompanied with mild lower abdominal pain, without any relevant past history. After clinical assessment she was diagnosed of incomplete abortion in an eleven week pregnancy, and indicated for uterine evacuation by manual vacuum aspiration. Upon aspiration, the student doctor noticed that bowel was coming from the uterus. He immediately stopped and referred her to the Regional hospital for management. Upon arrival at the Regional Hospital, she had a good general condition and normal vital parameters, her abdomen was also soft. On inspection of the vulva, small bowel was exteriorised which was worsen by

Discussion
Abortion is the termination of pregnancy before viability, and in developing countries viability is attained after 28 completed weeks.
There are spontaneous and induced abortions, and spontaneous abortions can be a threat, inevitable, incomplete, complete, missed or habitual abortions. Abortion is a serious condition in obstetrics and gynaecology. In Cameroon global figures on abortion are absent but a recent study reported that 26.3% of women attending obstetrics/gynaecological clinics have had a voluntary induced abortion [3]. Abortion is one of the main causes of maternal death worldwide and especially in sub Saharan Africa. In a systemic analysis, Say et al found abortion to be the forth direct cause of maternal death (8%) after haemorrhage (27%), hypertensive disorders (14%), and sepsis (11%) [4]. According to this review abortion was still forth in Sub-Saharan Africa but represented 10% of all maternal death. In Cameroon, a recent study at the Yaoundé Teaching Hospital reported unsafe abortion to be the second cause of maternal death (25%), after haemorrhage [5]. The management of incomplete abortion has evolved from dilatation and curettage to manual vacuum aspiration, although in some cases curettage is still used. This evolution was due to the numerous complications following uterine curettage. Immediate complications of uterine curettage include: haemorrhage, uterine perforation, and Ashermann syndrome [6]. Manual vacuum aspiration has credit of lesser complications and ease of use [7]. Westfall

Conclusion
Manual vacuum aspiration has been reported be an effective and safely method of uterine evacuation following an abortion. Some studies have reported uterine rupture following the use of MVA usually due to the suction cannula. Severe injuries such as bladder and bowel injury can occur following these perforations. We just reported a case of small bowel exteriorisation from uterine perforation using manual vacuum aspiration for an incomplete abortion.

Competing interests
The authors declare no competing interest in the presentation of this case.

Authors' contributions
Efuetnkeng Bechem: managed the case and wrote the article.