Uterine perforation is a perforation of the organ wall during intrauterine manipulations. It is manifested by intense pain in the lower abdomen and signs of intra-abdominal bleeding: bloody discharge from the vagina, weakness, dizziness, tachycardia. It can be combined with traumatization of the abdominal organs. Uterine perforation is detected on the basis of anamnesis, clinical data, transvaginal ultrasound, hysteroscopy and laparoscopy. Depending on the severity of the defect, either conservative and wait-and-see tactics are used, or surgical intervention is performed (suturing of a perforated hole, amputation / extirpation of the uterus).
Uterine perforation is a through-through damage to the uterine wall by surgical instruments during intrauterine procedures. In gynecology, it refers to iatrogenic pathology caused by careless actions of medical personnel. Uterine perforation occurs in 1% of gynecological patients who have undergone intracavitary manipulations (abortions, SDC, probing of the uterine cavity, hysteroscopy, etc.). There is a complete (through) perforation of the uterus with damage to the entire thickness of the wall and incomplete (without perforation of the serous membrane). At the same time, complete perforation can be uncomplicated (with intact internal organs) and complicated (with traumatization of the appendages of the uterus, bladder, intestines, omentum, etc.). Perforation of the uterus is a formidable complication, since it can lead to life-threatening bleeding, peritonitis, loss of reproductive function.
Regardless of the direct producing causes, a violation of the technique of performing gynecological manipulations always leads to perforation of the uterus: abortion, removal of the fetal egg during frozen pregnancy, diagnostic curettage, diagnostic hysteroscopy, hysteroresectoscopy, laser reconstruction of the uterine cavity, separation of intrauterine synechiae, installation of IUD.
Statistically, perforation of the uterine wall occurs more often during artificial termination of pregnancy. In this case, perforation can occur at any stage of a minor surgical operation: during probing of the uterine cavity (2-5%), expansion of the cervical canal (5-15%), removal of the fetal egg with an abortion or curette (80-90%). If damage to the uterus by a probe usually does not entail profuse internal bleeding and injury to the pelvic organs, then gross dilation of the cervical canal by Gegar dilators can lead to tears of the internal pharynx, perforation of the isthmus and the lower segment of the uterine body. The most dangerous is the perforation of the uterus with a curette and an abortion ring – in this case, the perforation hole may be located in the area of the bottom or walls of the uterus, have large dimensions. Such perforation is often accompanied by copious blood loss and injuries to the abdominal organs.
Predisposing factors that increase the likelihood of perforation should be considered pronounced retroflexia of the uterus, hypoplasia of the uterus, acute and chronic endometritis, endometrial cancer, the presence of a postoperative scar on the wall of the organ, age-related involution of the uterus. In addition, the risk of perforation increases significantly in cases where an artificial abortion is performed in out-of-hospital conditions, for a period of more than 12 weeks of pregnancy, the actions of the operating gynecologist are rough and hasty, instruments are inserted into the uterine cavity without sufficient visual, ultrasound or endoscopic control.
Signs of uterine perforation depend on its nature (complete/incomplete, complicated/uncomplicated) and localization. If an incomplete perforation has occurred or the perforation is covered by an organ (for example, an omentum), symptoms may be absent or poorly expressed. It is possible to think about perforation of the uterus if, after undergoing intrauterine manipulation, the patient complains of sharp pains in the lower abdomen, abundant bloody discharge from the vagina, dizziness and weakness. With significant internal bleeding, there is pallor of the skin, tachycardia, a drop in blood pressure, tension of the abdominal wall.
Untimely diagnosis of uterine perforation can lead to formidable and life-threatening complications and consequences. These include intestinal injuries or bladder injuries, massive hematomas, bleeding, peritonitis, sepsis. Damage to the internal uterine pharynx can contribute to the formation of cervical insufficiency, miscarriage during subsequent pregnancy. Uterine perforation can have serious consequences for reproductive function and cause the development of infertility due to the formation of intrauterine adhesions (Asherman syndrome) or the need to remove the uterus.
Directly during the intrauterine intervention, it is possible to suspect the perforation that has occurred by the feeling of the instrument “sinking” outside the uterine cavity. In complicated cases, perforation is indicated by the extraction of the bowel loop, omentum, ovary from the uterus. A sign of uterine perforation during the installation of an intrauterine contraceptive is the absence of threads visible during vaginal examination in the area of the uterine pharynx, and if there are any, the inability to extract the IUD “by the mustache” (a feeling of resistance, sharp pain).
If the manipulation is performed under hysteroscopic control, then the endoscopist can focus on the following signs: it is not possible to maintain stable pressure in the uterine cavity, there is no outflow of injected fluid, the peritoneum, intestinal loops or other internal organs are visible on the monitor. If the operating surgeon has reason to assume that a perforation of the uterus has occurred, he should immediately suspend all actions and try to palpate the end of the instrument through the abdominal wall to make sure of its location.
In cases where uterine perforation is not recognized on the operating table, careful monitoring of the patient in the first hours after manipulation, analysis of complaints and obstetric and gynecological history helps in the timely diagnosis of complications. Additional information is obtained using a transvaginal ultrasound, which allows you to detect free fluid in the pelvis. In most cases of uterine perforation, diagnostic laparoscopy is performed to exclude damage to the abdominal organs.
Further tactics in uterine perforation are determined by the timeliness of defect recognition, its magnitude, localization, the mechanism of injury, and the interest of internal organs. If the perforation is incomplete, the hole is small, and there is absolute confidence in the absence of damage to the OBP, parametral hematoma and intra-abdominal bleeding, conservative-observational tactics can be undertaken. In this case, bed rest is prescribed, cold on the stomach, uterotonic drugs and antibiotics are used. Dynamic ultrasound control is carried out.
In other situations (in the presence of peritoneal symptoms and increasing signs of internal bleeding), laparoscopy or laparotomy, a thorough revision are indicated. If a small defect is detected in the uterine wall, they are limited to suturing the wound. If multiple or large ruptures of the uterine wall are detected, the issue is resolved in favor of supravaginal amputation (removal of the uterus without a cervix) or even hysterectomy (complete removal of the uterus). In case of perforation of the uterus complicated by injury of adjacent organs, the volume of the operating allowance is supplemented with appropriate interventions. In order to replenish blood loss, infusion therapy, transfusion of blood components is carried out, and antibacterial therapy is used to prevent infectious complications.
Prognosis and prevention
The prognosis for a woman’s life with timely diagnosis and elimination of uterine perforation is favorable, but the consequences for reproductive function can be the most serious. In order to prevent perforation of the uterus, it is necessary to observe the technique and stage-by-stage of various intrauterine interventions, insert instruments into the uterine cavity carefully, if possible under visual control. The patient herself can minimize the risk of uterine perforation by refusing abortions and regularly visiting a gynecologist. Women who have suffered perforation of the uterine wall are subject to registration at the dispensary. Pregnancy management in such patients is associated with many risks, primarily with the risk of miscarriage and rupture of the uterus.