The document describes a case study of a 25-year-old unmarried woman who presented with heavy menstrual bleeding and was diagnosed with septic incomplete abortion and severe anemia. She was treated surgically and received blood transfusions and antibiotics. The document then provides background information on unsafe abortion, its prevalence in Nepal, and the country's abortion law which legalized abortion in certain conditions. It discusses methods of surgical and medical abortion and challenges to accessing safe abortion services in Nepal.

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.

8. SEPTIC INCOMPLETE
ABORTION WITH SEVERE
ANAEMIA

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.

15.  Maternal Mortality Ratio-
281/100,000 live births (MMR study 2006)
 Unintended Pregnancies
33% (DHS, ORC Macro, 2002)
 Contraceptive Prevalence Rate
44% (DHS 2006)
 Total Fertility rate
3.6 (DHS 2006)

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)

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

22. Surgical:
 Manual vacuum aspiration-up to 12 weeks
 D+C-dilation and curettage-less used-1st
trimester
 D+E-Dilation +evacuation-2nd trimester
12-16 weeks

26.  Prostaglandins E1 (Misoprostol- causes
myometrial contractility & cervical softening)
 Mifepristone + prostaglandins- 8-10 weeks
 Methotrexate+prostaglandins-through week 9
(rarely used)

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.

30.  www.ipas.org ©2009 Ipas.
 UNICEF nepal
 ^ "WHO: Unsafe Abortion - The Preventable
Pandemic".
http://www.who.int/reproductivehealth/publications/un
safe_abortion. Retrieved 2010-01-16.
 Kathmandu University Medical Journal (2009), Vol. 7,
No. 1, Issue 25, 31-39
-Baseline survey on functioning of abortion services in government
approved CAC centres in three pilot districts of Nepal
Karki C1, Ojha M2, Rayamajhi RT3