Uterine damage is a violation of the anatomical integrity of the tissues of the cervix or the body of the uterus, due to the influence of mechanical, chemical, thermal, radiation and other factors. Uterine damage is usually accompanied by bleeding, pain in the lower abdomen; the formation of fistulas is possible. In the future, such injuries can lead to miscarriage or infertility. Uterine damage is detected by gynecological examination, cervicoscopy, hysteroscopy, ultrasound, diagnostic laparoscopy. Treatment tactics (conservative or operative) depends on the type of damaging factor and the nature of the injury.
Uterine injuries are various kinds of injuries that lead to the formation of anatomical defects and disruption of organ function. They occur more often during medical interventions and childbirth, but may occur outside of these events. Injuries of the uterus in gynecology include bruises, ruptures, perforations, fistulas, radiation, chemical and thermal injuries. Uterine injuries often require emergency care, as they are accompanied by bleeding, pain shock, infection and can lead to serious violations of reproductive function in the future. Birth injuries are considered in detail by us separately, since they have their own causes and characteristics. As for injuries of the internal genitals associated with bruises, intrauterine manipulations, operations or sexual intercourse, they account for approximately 0.5% of all causes of hospitalization in gynecological hospitals.
Injuries such as ruptures of the cervix or the body of the uterus occur more often during childbirth, but they can also occur during artificial abortion or diagnostic curettage. Birth injuries are usually associated with the birth of a large fetus, rapid childbirth, scar deformation or rigidity of the cervix, the use of obstetric aids in childbirth (the imposition of obstetric forceps, vacuum extraction of the fetus and fruit-destroying operations, etc.). The cause of rupture of the uterus, as a rule, is the failure of the scar left after cesarean section, myomectomy, suturing uterus. In these cases, it is possible to rupture the uterus along the scar during the next pregnancy and labor.
Uterine damage by the type of ruptures is sometimes observed when foreign objects with a sharp end are inserted into the vagina. Traumatic necrosis of the cervix develops as a result of compression of the cervix between the pelvic walls of the woman in labor and the fetal head. A similar situation may occur with a narrow pelvis, weak labor activity, scarring of the cervix. Uterine perforation is associated with iatrogenic causes – erroneous or rude actions of medical staff during abortion, probing of the uterine cavity, SDC, hysteroscopy, intrauterine contraceptive administration and other intrauterine procedures. Various pathological conditions can also contribute to perforation of the uterine wall: postoperative scars, endometrial cancer, endometritis, etc.
Uterine bruises are more common in pregnant women; they can be caused by a fall, a blow to the stomach with a blunt object, a car accident. Abdominal uterine, vesico-uterine, ureteral-uterine fistulas can occur due to birth injuries, surgical interventions with secondary wound healing, iatrogenic damage to the bladder or ureters during gynecological operations, the collapse of malignant tumors, radiation exposure, etc.
Thermal and chemical uterine damage is rare. Thermal injuries usually occur due to douching with too hot solutions. Chemical uterine damage can be caused by the use of cauterizing substances (silver nitrate, aceti*+-
c acid or nitric acid), as well as the deliberate introduction of chemicals into the uterine cavity for the purpose of criminal abortion.
Contusion of the uterus
The risk of such uterine damage increases in pregnant women in proportion to the increase in gestational age. Isolated bruises of the uterus can provoke spontaneous termination of pregnancy at any time, premature placental abruption or premature birth. These complications are usually indicated by spotting from the genital tract, abdominal pain, increased uterine tone. In case of damage to the chorionic villi, fetal-maternal transfusion may develop, in which fetal blood enters the bloodstream of a pregnant woman. This condition is dangerous for the development of fetal anemia, fetal hypoxia, as well as stillbirth. With severe blunt abdominal trauma, ruptures of the liver, spleen, uterus are also possible, and therefore massive intra-abdominal bleeding develops.
To determine the severity of the injury, the condition of the pregnant woman and the fetus, in addition to traditional physical and laboratory tests, a gynecological examination, ultrasound of the uterus and fetus, CTG is performed. In order to detect blood in the pelvic cavity, a culdocentesis or peritoneal lavage is performed.
Treatment of uterine injuries and their consequences is carried out taking into account the severity of the injury and the gestation period. With mild bruises and early gestation, dynamic monitoring with ultrasound control and CTG monitoring can be carried out. With pregnancy terms close to full-term, the question of early delivery is raised. If blood is found in the abdominal cavity, an emergency laparotomy is performed, bleeding is stopped and the damaged organs are sutured. Feto-maternal transfusion may require intrauterine blood transfusion.
Minor ruptures of the cervix may be asymptomatic. With extensive and deep defects, bloody discharge of bright red color appears: blood can flow out in a trickle or stand out with clots. Cervical ruptures are usually recognized by the clinic or by examining the cervix in mirrors. With such injuries, catgut sutures are applied to the cervix. If such uterine injuries were not detected in a timely manner or properly sutured, in the future they may be complicated by the formation of a hematoma in parametria, cervicitis, postpartum endometritis, ectropion and erosion of the cervix.
Rupture of the uterus is accompanied by acute cutting pain in the abdomen, pallor of the skin and mucous membranes, falling blood pressure, cold sweat. If the rupture occurred in the active phase of labor, then labor activity stops. There are signs of intra-abdominal bleeding and bleeding from the genital tract. The parts of the fetus are determined directly under the anterior abdominal wall. The general condition of the patient is extremely serious. Uterine damage by the type of rupture is diagnosed on the basis of a general objective and external obstetric examination, ultrasound, cardiotocography. In this case, immediate delivery by Caesarean section, revision of the uterus and abdominal cavity is indicated. Possible options for surgical treatment are suturing of the rupture, supravaginal amputation or radical removal of the uterus.
Perforation of the uterus
When the uterine wall is pierced with a surgical instrument, intra-abdominal or mixed bleeding develops. Patients at the same time feel sharp pain in the lower abdomen, complain of spotting, dizziness and weakness. With massive internal bleeding, arterial hypotension, tachycardia, and pallor of the skin are noted. Along with uterine damage, injury to the bladder or intestines may occur. The most common complication of uterine perforation is peritonitis.
Perforation of the uterine wall can be recognized even during intrauterine manipulation by characteristic signs (the feeling of a “failure” of the instrument, visualization of intestinal loops, etc.). The diagnosis in this case is confirmed by hysteroscopy, transvaginal ultrasound of the pelvic organs. The main method of treatment of end–to-end uterine injuries is surgical (suturing of the rupture, subtotal or total hysterectomy).
Abdominal uterine fistulas connect the uterine cavity with the anterior abdominal wall and are external. The outlet of the fistula often opens in the area of the suture or postoperative scar. The presence of a fistula is supported by inflammatory infiltration of the fistula. It is manifested by the periodic release of blood and pus through the cutaneous opening of the fistula. Fistulas are detected during examination and hysteroscopy. Treatment – excision of the fistula and suturing of the uterus.
The main signs of a vesico-uterine fistula are cyclic menuria (a symptom of Yussif), urine discharge from the vagina, a symptom of “laying” a stream of urine during the formation of blood clots in the bladder, secondary amenorrhea. Ureteral-uterine fistulas are manifested by leakage of urine from the vagina, lower back pain, fever caused by hydroureteronephrosis. Genitourinary fistulas are detected during the examination of the vagina in mirrors, cystoscopy, hysterography. Treatment – surgical closure of fistulas (fistuloplasty), ureteral plastic surgery.
Utero-intestinal fistulas may be the result of perforation of the uterus with damage to the intestine, a breakthrough in the intestine of an abscess that developed after conservative myomectomy or cesarean section. The course of intestinal-uterine fistulas of inflammatory genesis is recurrent. Before the breakthrough of the abscess into the colon, pains in the lower abdomen, hyperthermia, chills, tenesmus increase. Mucus and pus appear in the feces. After emptying the abscess, the patient’s condition improves. However, due to the fact that the fistula opening is rapidly undergoing obliteration, pus soon accumulates again in the cavity of the abscess, which causes a new exacerbation of the disease.
For diagnosis, vaginal examination with mirrors, combined gynecological ultrasound, rectovaginal examination, rectoromanoscopy, fistulography, CT and MRI of the pelvis are used. Tactics for pathology of this kind are only surgical; it includes “intestinal” and “gynecological” stages. The details of the intervention are determined by the operating gynecologist and proctologist. Excision of necrotic tissues and restoration of intestinal integrity is usually combined with supravaginal amputation or extirpation of the uterus.
Chemical and thermal uterine damage
In the acute period after uterine damage of this kind, the clinic of endomyometritis develops. He is concerned about an increase in body temperature, pain in the lower abdomen, sometimes – spotting caused by rejection of necrotically altered uterine mucosa. Such injuries can be complicated by peritonitis and sepsis. After the healing of thermal and chemical damage, scarring of the cervix, cervical canal atresia, intrauterine synechiae may form. In the long-term period, the development of hypomenstrual syndrome or amenorrhea, infertility is likely.
Diagnosis is based on clarifying the anamnesis (revealing the fact of the introduction of hot solutions or chemicals into the vagina), examination data of the cervix in mirrors, gynecological ultrasound. Treatment – detoxification and antibacterial therapy. With the development of peritonitis, laparotomy, sanitation and drainage of the abdominal cavity are performed; with extensive necrotic lesions of the uterus, extirpation of the organ is performed. In the future, to restore the patency of the cervical canal, its augmentation is performed. In Asherman syndrome, hysteroscopic separation of synechiae is shown.