Aluminum phosphide (AlP) is an efficient and toxic pesticide that is easily available in many Asian countries such as Iran. Many cases of unintentional or suicidal use of AlP have been reported in these countries, and these statistics are rising rapidly. We aim to present a case of abortion induced by vaginal use of AlP. We report a 44-year-old gravid woman who self-administered one-quarter of a 3-g AlP tablet intravaginally. Ultrasound at 6 hours post-admission showed no fetal movement or heart motion. Intravaginal administration of AlP can lead to fetal death and abortion. There is concern about the spread of vaginal use of these agents in pregnant women, as the number of illegal abortions is increasing

Azami, Golnaz

Bazgir, Nasrin

Hashemi, Fatemeh-Sadat

Khalighi, Zahra

Shafiei, Elham

English

Journals Portal, Shahid Beheshti University of Medical Sciences

1Case Report: Induced Abortion by Vaginal Use of Aluminum Phosphide in a 44-Year-Old Woman: A Case ReportZahra Khalighi1 , Fatemeh-Sadat Hashemi1, Nasrin Bazgir2, Golnaz Azami3, Elham Shafiei3* 1. Department of Internal Medicine, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran. 2. Department of Rheumatology, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran.3. Clinical Research Development Unit, Shahid Mostafa Khomeini Hospital, Ilam University of Medical Sciences, Ilam, Iran. * Corresponding Author: Elham Shafiei, PhD.Address: Clinical Research Development Unit, Shahid Mostafa Khomeini Hospital, Ilam University of Medical Sciences, Ilam, Iran.Tel: +98 (84) 32235724E-mail: shafiei-e@medilam.ac.irAluminum phosphide (AlP) is an efficient and toxic pesticide that is easily available in many Asian countries such as Iran. Many cases of unintentional or suicidal use of AlP have been reported in these countries, and these statistics are rising rapidly. We aim to present a case of abortion induced by vaginal use of AlP. We report a 44-year-old gravid woman who self-administered one-quarter of a 3-g AlP tablet intravaginally. Ultrasound at 6 hours post-admission showed no fetal movement or heart motion. Intravaginal administration of AlP can lead to fetal death and abortion. There is concern about the spread of vaginal use of these agents in pregnant women, as the number of illegal abortions is increasing.A B S T R A C TKeywords:Aluminum phosphide, Poisoning, AbortionCitation: Khalighi Z, Hashemi F, Bazgir N, Azami G, Shafiei E. Induced Abortion by Vaginal Use of Aluminum Phosphide in a 44-Year-Old Woman: A Case Report. International Journal of Medical Toxicology and Forensic Medicine. 2020; 10(2):29025. https://doi.org/10.32598/ijmtfm.v10i2.29025 : https://doi.org/10.32598/ijmtfm.v10i2.29025Use your device to scan and read the article onlineArticle info: Received: 13 Feb 2020First Revision: 20 Feb 2020Accepted: 05 Mr 2020Published: 28 Jun 20201. Introductionluminum phosphide (AlP) is a very toxic and effective fumigant pesticide that is widely used in many countries such as Iran because of its efficacy, low cost, and easy usage [1-4]. The toxin is absorbed by respiration, ingestion, and dermal contact. It is very reactive, and any contact with moisture causes its de-composition to phosphine gas:AlP+3H2O → AL (OH)3+PH3Inhalation of phosphine gas happens when AlP is exposed to moisture in stored grain, which is also the most common form of exposure. Oral exposure ranges from the deliberate suicidal attempts to unintentional ingestions [5]. Ingesting 500 mg or more AlP could result in death. Upon ingestion, gastric acid converts phosphides to phosphine gas [6]. Subsequently, phosphine gas is ab-sorbed from the gastrointestinal tract into the blood-stream. Human exposure to AlP can be through inhala-tion or absorption through the skin. ASpring 2020, Volume 10, Number 22Phostoxin is a highly acute toxic substance. Phostox-in gassing tablets contain AlP, which reacts with normal atmospheric moisture to liberate phosphine (hydrogen phosphide) gas. Exposure to even small amounts of phos-phine can cause headache, dizziness, nausea, vomiting, diarrhea, drowsiness, cough, and chest tightness. More severe exposure can cause shock, convulsions, coma, ir-regular heartbeat, and liver and kidney damage [5].  Several mechanisms of toxicity have been proposed, including inhibition of cytochrome oxidase C, electron transport chain blocking, and cellular respiratory disrup-tion that causes inhibition of acute thrombocytopenic purpura. It produces oxygen free radicals and cholines-terase inhibition [4, 6-8].  Death results from refractory cardiogenic shock due to myocardial dysfunction [9-11]. The symptomatology is brutal with the appearance of digestive signs and car-diovascular anomalies. The immediate prognosis is de-termined by the presence of acute pulmonary edema or cardiogenic shock [12]. In pregnant women, oral usage of AlP for abortifacient purposes has been very little reported, and the direct fetal effect of this product remains uncertain [13]. This paper reports an unusual case of intravaginal use of AlP for illegal abortion in a 44-year-old woman. 2. Case PresentationA 44-year-old woman with the gestational age of 11 weeks and 6 days was admitted to the maternity ward of Taleghani Hospital, Ilam, Iran (4 PM) after vaginal usage of one-quarter of a 3-g AlP tablet. After about 3.5 hours of toxin usage, she fell unconscious. It has been specu-lated that the changes in consciousness could be due to weakness and lethargy. About 30 minutes later, her hus-band brought her to the hospital. On admission, she was conscious. She was alert and oriented to time, person, place, and situation. The patient was examined after hos-pital admission and had the blood pressure of 100/70 mm Hg, respiration of 16 breaths/min, pulse rate of 84 beats/min, and body temperature of 37.10°C. The patient vital signs during hospital stay were recorded (Table 1).Abdominal pain, nausea, and vomiting were not present. Gynecological examination showed no abdominal swell-ing, no sign of irregular contraction of the uterus, and a small amount of vaginal bleeding. In the vaginal examina-tion, no tablet remnants were seen or palpated. Other ex-aminations were normal.  There is no description of vagi-nal bleeding or abdominal pain over the past week. The patient denied having a history of previous illness, allergy, medication use, smoking, or any substance abuse, food, or drug sensitivity.  Six and half hours later, she was admitted to the poisoning ward. In physical examination, her pupils were midsize, symmetrical, and reactive to light. Cardiovascular and respiratory examinations were unre-markable. Additional laboratory tests and fetal ultrasound evaluations were performed as directed by the gynecolo-gist. Table 2 presents the laboratory results. All labora-tory findings were normal except for a mild decrease in Alanine Aminotransferase (ALT) levels. The possible ex-planation could be the toxic necroinflammatory response followed by the vaginal administration of AlP. The reduc-tion of ALT levels is an expression of healing.The patient was admitted to the clinical toxicologist ser-vice and transferred to the poisoning ward. On admission to the poisoning ward, she was conscious, had no com-plication, and her physical examination was normal. The patient remained on cardiac monitoring during recovery, and her vital signs were recorded.  One liter of normal saline was charted over 12 hours. Results of the arterial blood gas are presented in Table 3. The ABG results on admission indicated a partially compensated respiratory alkalosis, which is induced by hyperventilation. In the current study, central sources are toxin usage, fear, stress, and anxiety-hyperventilation. Hypoxic stim-ulation leads to hyperventilation in an attempt to correct hypoxia at the expense of CO2 loss [14]. Respiratory al-kalosis in itself is not life-threatening. Interventions to reduce pH directly are typically not necessary as there are no mortality benefits to this therapy [14]. The ABG results on 6 hours post-admission indicated compensated respiratory alkalosis.Six hours post-admission, an ultrasound was carried out. On ultrasonography, a hypoechoic area (11*38 mm) ap-peared, which consisted of the retained product of concep-tion. The fetal heartbeat was not detected. Two hours later, spontaneous expulsion of the fetus (miscarriage) follow-ing abnormal bleeding occurred.  After the abortion, her vital signs and bleedings were monitored continuously. Her vital signs were normal, and no other complications occurred. The patient was discharged after 12 hours in the hospital. The physician scheduled a follow-up a week af-ter the discharge. She did not address any complications.   3. DiscussionHere, we presented a rare case of intravaginal use of aluminum phosphide to induce abortion. To the best of our knowledge, there is no reliable data on the outcome of aluminum phosphide exposure on pregnancy. Khalighi Z, et al. Induced Abortion by Vaginal Use of Aluminum Phosphide. IJMTFM. 2020; 10(2):29025.Spring 2020, Volume 10, Number 23The toxicity of the AlP is mainly due to the phosphine gas liberated in contact with moisture.  Phosphine gas, the active form of AlP, is rapidly absorbed by ingestion, inhalation, skin, or musical contacts. In this case, phos-phine gas could be the main cause of abortion. Czeizel AE, Tı́már L, Susanszky E (2017) conducted a population-based prospective study to examine the timing and consequences of suicide attempts by self-poisoning during pregnancy [15]. The result of this study indicated that 61% of suicide attempts occurred before the third post-conceptual month. Most suicidal attempts occurred after the early recognition of unwanted pregnancies and most resulted in a very early fetal loss [15]. These findings are comparable with the present results, in which the suicidal attempt in our case occurred before the third post-conceptual month and resulted in a very ear-ly fetal loss. These findings can highlight the importance of screening for the early detection of suicidal behaviors, especially in pregnant women in the first trimester. To the best of our knowledge, few studies reported the aluminum phosphide poisoning and its effect on pregnancy. To date, evidence on the impact of AlP on Table 1. Vital signs of the patient during the hospital stayStage BP PR RR TVital sign on admission 100/70 mm Hg 84 b/m 16 br/m 37.1°C6.5 hours post-admission 139/78 mm Hg 92b/m 16 br/m 37.1°C7.5 hours post-admission 128/79 mm Hg 96b/m 16br/m 37.2°C8.5 hours post-admission 105/75 mm Hg 100 b/m 16 br/m 37.1°C13 hours post-admission 105/75 mm Hg 105 b/m 15 br/m 37°CBP: blood pressure; PR: pulse rate; RR: respiratory rate; T: Temperature Table 2. Laboratory results Normal RangesValuesFactors5,000 to 10,000 µL of blood8300*10³/µL (poly 80%, lymph 20%)White blood cells12-15.5 g/dL12.1 g/dL (MCV79)Hemoglobin150,000-  450,000 10³/L221*10³/LPlatelet5 to 20 mg/dL16 mg/dLUrea0.7 to 1.2 mg/dL0.97 mg/dLCreatinine44 to 147 IU/L120 IU/LAlkaline Phosphatase10 to 40 units per liter11 U/LAspartate Aminotransferase (AST)20-60 IU/L13 IU/LAlanine Aminotransferase (ALT) Table 3. Blood gas analysis of the patient during the hospital stayAnalysis pH PCO2 PO2 HCO3 Base Excess (BE)Blood Gas Analysis on Admission 7.46 24 mm Hg 31 mm Hg 17.7mmol/L -4.5 mmol/LBlood Gas Analysis 6 Hours Post Admission 7.43 25 mm Hg 23 mm Hg 16.6 mmol/L -6.1 mmol/LKhalighi Z, et al. Induced Abortion by Vaginal Use of Aluminum Phosphide. IJMTFM. 2020; 10(2):29025.Spring 2020, Volume 10, Number 24abortion is not enough.  The death of a pregnant woman following exposure to aluminum phosphide has already been reported [16]. In pregnant women, the vaginal use of AlP for abortion has not been reported, and the direct fetal effect of this product has remained uncertain.  There is no study on the specific impact of AlP on the course of pregnancy and, in particular, its teratogenic effect. The harmful effect of AlP on the fetus is probably exerted through both systemic maternal complications (acute circulatory insufficiency, hypoxemia) and transplacental transfer of the hydrogen phosphorus [13]. The researchers planned to perform the anatomopatho-logical examination to investigate the exact cause of fetal death, but the patient did not consent to it. The previously conducted study reported that transplacental transfer of the hydrogen phosphorus is probably the main cause of fetal death. They hypothesized that the mixture of alumi-num phosphide and ammonium carbonate might regulate the shift in phosphorus hydrogen [13]. Based on our observation, in this case, there were no systemic effects on mother, and serum toxicology was negative. It was ideal to measure the toxin level in the fetus tissue, but as we mentioned earlier, the patient did not consent to proceed with the procedure. Further studies are needed to determine the exact mechanism of action for vaginal usage of AlP on induced abortion and fetal death. Furthermore, there are concerns about the increase of using AlP for abortion, as the patient believed that her action was successful. Ethical ConsiderationsCompliance with ethical guidelinesAll ethical principles were considered in this article. The participants were informed about the purpose of the research and its implementation stages; they were also assured about the confidentiality of their informationFundingThis study was supported by the Deputy of Research of Ilam University of Medical Sciences.Author's contributionsAll authors contributed in preparing this article.Conflict of interestThe authors declared no conflict of interest.AcknowledgementsAuthors would like to thank the colleagues from Clini-cal Research Development Unit, Mostafa Khomeini Hospital, who provided insight and expertise that greatly assisted the research.References[1] Etemadi-Aleagha A, Akhgari M, Iravani FS. Aluminum phosphide poisoning-related deaths in Tehran, Iran, 2006 to 2013. Medicine (Baltimore). 2015; 94(38):e1637. [DOI:10.1097/MD.0000000000001637] [PMID] [PMCID] [2] Moradi M, Ghaemi K, Mehrpour O. A hospital base epi-demiology and pattern of acute adult poisoning across Iran: A systematic review. Electron Physician. 2016; 8(9):2860-70. [DOI:10.19082/2860] [PMID] [PMCID] [3] Banjaj R, Wasir H. Epidemic aluminium phosphide poi-soning in northern India. Lancet (London, England). 1988; 1(8589):820. [DOI:10.1016/S0140-6736(88)91676-5] [4] Proudfoot AT. Aluminium and zinc phosphide poisoning. Clin Toxicol (Phila). 2009; 47(2):89-100. [DOI:10.1080/15563650802520675] [PMID] [5] National Center for Biotechnology Information. PubChem Database. Aluminum phosphide, CID=30332 [Internet]. 2020 [Updated 20 Mar 2020]. Available at: https://pubchem.ncbi.nlm.nih.gov/compound/Aluminum-phosphide[6] Tilley DDS. Competency in nursing: A concept analysis. J Contin Educ Nurs. 2008; 39(2):58-64. [DOI:10.3928/00220124-20080201-12] [PMID] [7] Stephenson J. Zinc phosphide poisoning. Arch Environ Health. 1967; 15(1):83-8. [DOI:10.1080/00039896.1967.10664880] [PMID] [8] Singh S, Bhalla A, Verma SK, Kaur A, Gill K. Cytochrome-c oxidase inhibition in 26 aluminum phosphide poi-soned patients. Clin Toxicol (Phila). 2006; 44(2):155-8. [DOI:10.1080/15563650500514467] [PMID] [9] Chugh SN, Dushyant, Ram S, Arora B, Malhotra KC. Inci-dence & outcome of aluminium phosphide poisoning in a hospital study. Indian J Med Res. 1991; 94:232-5. [PMID] [10] Siwach S, Singh H, Katyal V, Bhardwaj G. Cardiac arrhyth-mias in aluminium phosphide poisoning studied by on con-tinuous holter and cardioscopic monitoring. J Assoc Physi-cians India. 1998; 46(7):598-601. [PMID] [11] Chugh S, Chugh K, Ram S, Malhotra K. Electrocardio-graphic abnormalities in aluminium phosphide poisoning with special reference to its incidence, pathogenesis, mortal-ity and histopathology. J Indian Med Assoc. 1991; 89(2):32-5. [PMID] [12] Hajouji MI, Oualili L, Abidi K, Abouqal R, Kerkeb O, Zeggwagh AA. [Severity factors of aluminium phosphide poisoning (Phostoxin) (french)]. Ann Fr Anesth Reanim. 2006; 25(4):382-5. [DOI:10.1016/j.annfar.2005.12.004] [PMID] Khalighi Z, et al. Induced Abortion by Vaginal Use of Aluminum Phosphide. IJMTFM. 2020; 10(2):29025.Spring 2020, Volume 10, Number 25[13] Mouhaoui M, Khaleq K, Rabbai O, Yaqini K, Louardi H. [Aluminium phosphide poisoning and pregnancy (case re-port) (French)]. Ann Fr Anesth Reanim. 2008; 27(2):181-2. [PMID] [14] Vanamee P, Poppell JW, Glicksman AS, Randall HT, Roberts KE. Respiratory alkalosis in hepatic coma. AMA Arch Intern Med. 1956; 97(6):762-7. [DOI:10.1001/archinte.1956.00250240114011] [PMID] [15] Czeizel AE, Tı́már L, Susanszky E. Timing of suicide attempts by self‐poisoning during pregnancy and preg-nancy outcomes. Int J Gynecol Obstet. 2017; 65(1):39-45. [DOI:10.1016/S0020-7292(99)00007-7] [16] Garry VF, Good PF, Manivel JC, Perl DP. Investigation of a fatality from nonoccupational aluminum phosphide expo-sure: measurement of aluminum in tissue and body fluids as a marker of exposure. J Lab Clin Med. 1993; 122(6):739-47. [PMID]Khalighi Z, et al. Induced Abortion by Vaginal Use of Aluminum Phosphide. IJMTFM. 2020; 10(2):29025.Spring 2020, Volume 10, Number 2This Page Intentionally Left Blank

Induced Abortion by Vaginal Use of Aluminum Phosphide in a 44-Year-Old Woman: A Case Report

Aluminum phosphide (AlP) is an efficient and toxic pesticide that is easily available in many Asian countries such as Iran. Many cases of unintentional or suicidal use of AlP have been reported in these countries, and these statistics are rising rapidly. We aim to present a case of abortion induced by vaginal use of AlP. We report a 44-year-old gravid woman who self-administered one-quarter of a 3-g AlP tablet intravaginally. Ultrasound at 6 hours postadmission showed no fetal movement or heart motion. Intravaginal administration of AlP can lead to fetal death and abortion. There is concern about the spread of vaginal use of these agents in pregnant women, as the number of illegal abortions is increasing. © 2020 Shahid Beheshti University of Medical Sciences. All rights reserved

Khalighi, Z.

Hashemi, F. S.

Bazgir, N.

Azami, G.

Shafiei, E.

Research Repository Portal of Medilam

Letter to Editor                                                                  J Bas Res Med Sci 2016; 3(1):1-2 . 1  Healthy behaviors among carpet weavers in Golestan Province, Iran Ali Zafarzadeh1, Hashem Heshmati*2, Hamideh Meshkati3 1. Environmental health Research center, Faculty of Health, Golestan University of Medical Sciences, Gorgan, Iran 2. Department of Public Health, Faculty of Health, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran 3. Reaserch expert, Faculty of Health, Golestan University of Medical Sciences, Gorgan, Iran       The carpet industry developed various types of respiratory disorders, pulmonary function (1,2), musculoskeletal disorders, injuries, eyesight problems (1,3), nerve disorders, carpal tunnel syndrome (1,4) and skin problems (1,3). Developing such types of disorders occur as a result of poor environmental conditions coupled with unhygienic conditions (1, 5). On the other hand, lack of appropriate knowledge and perceived barriers among the weavers led to existing problems in the carpet industry. Most of these diseases and health problems can be avoided by proper precautions and care (1). According to the importance of the subject, the current study was designed and made with the aim of determining Healthy behaviors among carpet weavers in Golestan Province, Iran. This is a cross-sectional study with descriptive-analytical approach that was done in 2013. A total of 200 carpet weavers in Aq-qala and Bandar-Torkaman districts in Golestan province (northwest of Iran) were selected by using the census method. Data were collected by using a reliable and valid questionnaire through the interview. Data were analyzed through SPSS15 software and one way ANOVA. Mean age of the carpet weavers was 35.63±11.64 and the age range was 14-76 years old. All of the carpet weavers were women. The mean score of healthy behavior was 64.33±14.40(score range 0-100).11.5% of whom followed safety tips, 8.5% used mask, 42.5% of workshops had ventilation, 36% washed wools, 59% consumed fruit and vegetable, 51.5% of workshops had enough light, 26.5% vaccinated at the right time for tetanus. There was a significant association between behavior and educational level (P=0.024 F=3.20). Healthy behavior of carpet weavers was not in a desirable level. Another study in Iran (5) revealed hand woven carpet industry faces occupational health. So, it seems health status of carpet weavers should promote for preventing various disorders. We recommended appropriate interventions such as health service, education improvement and advocacy for promoting healthy behaviors of carpet weavers. Acknowledgments This study was supported by the Golestan University of Medical Sciences. Implication for health policy makers/practice/research/medical education: In order to design appropriate interventional program, especially educational intervention to reduce the prevalence of unhealthy behaviors in carpet weavers.  *Corresponding author: Tel: +98 913 4512051 Fax:+985152228021  Address: Department of Public Health, Faculty of Health, Torbat Heydariyeh University of Medical Science, Torbat Heydariyeh, Iran E-mail: heshmati.hashem@yahoo.com Received; 2014/02/4 revised; 2014/05/10 accepted; 2015/06/10  Downloaded from jbrms.medilam.ac.ir at 12:37 IRST on Wednesday March 14th 2018Letter to Editor                                                                  J Bas Res Med Sci 2016; 3(1):1-2 . 2  References  1. Wani KA, Jaiswal YK. Occupational Health Risk Factors in Carpet Industry: A Review. Asian   J   Exp BioL Sci. 2011; 2(1):135-9. 2. Rajsri TR, Gokulram N, Gokulakrishnan K, Chandrasekar M, Nikhil Chandrasekar. A study on pulmonary function tests in weavers. Int J Med Res Health Sci. 2013; 2(4):857-60. 3. Choobineh AR, Hosseini  M, Lahmi  MA, KhaniJazani  R, Shahnavaz  H. Musculoskeletal problems in Iranian hand woven carpet industry: Guidelines for workstation design. Appl Ergonom.   2007;38:617-24.  4. Şenveli  M, Türker  A, Arda  MN, Altinörs  MN. Bilateral carpal tunnel syndrome in a young carpet weaver. Clin Neurol Neurosurg. 1987;89(1):281-2. 5. Choobineh  AR, Shahnavaz  H, Lahmi  MA. Major Health Risk Factors in Iranian Hand Woven Carpet Industry. Int J Occup  Safety Ergonom (JOSE). 2004;10(1):65-78.    Downloaded from jbrms.medilam.ac.ir at 12:37 IRST on Wednesday March 14th 2018

Induced abortion by vaginal use of aluminum phosphide in a 44-year-old woman: A case report

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Induced Abortion by Vaginal Use of Aluminum Phosphide in a 44-Year-Old Woman: A Case Report

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