The perforated uterus ~Review

Hashem Yaseen ,MDHashem Yaseen ,MD33rdrd year OG resident \ KAUH year OG resident \ KAUH

IntroductionIntroduction Uterine perforation is an uncommon but

potentially serious complication of:1.1. uterine manipulationuterine manipulation2.2. evacuation of retained products of conception (ERPC)evacuation of retained products of conception (ERPC)3.3. termination of pregnancy (TOP)termination of pregnancy (TOP)4.4. During coil insertionDuring coil insertion5.5. hysteroscopic procedures hysteroscopic procedures

Factors that increase the risk of uterine perforation include:

1.1. uterine anomalies, uterine anomalies, 2.2. infection,infection,3.3. recent pregnancy recent pregnancy 4.4. PostmenopausePostmenopause

TOP is the most common procedure associated with uterine perforation. ~ ( ACOG)TOP is the most common procedure associated with uterine perforation. ~ ( ACOG)

Incidence and potential sequelaeIncidence and potential sequelae

With hysteroscopic surgery the incidence of uterine perforation has been With hysteroscopic surgery the incidence of uterine perforation has been reported at 1.6%. ~ (RCOG)reported at 1.6%. ~ (RCOG)

Most perforations are Most perforations are in the bodyin the body of the uterus and are often small, tending to of the uterus and are often small, tending to cause relatively little haemorrhage.cause relatively little haemorrhage.

internal cervical os and lower part of the uterus -> branches of the uterine internal cervical os and lower part of the uterus -> branches of the uterine vessels -> haematoma formation in the broad ligament or serious intra-vessels -> haematoma formation in the broad ligament or serious intra-peritoneal haemorrhage.peritoneal haemorrhage.

Up to 15% of uterine perforations caused by the fitting of an intrauterine device Up to 15% of uterine perforations caused by the fitting of an intrauterine device will involve abdominal or pelvic viscera (the intestines, ureter, urinary bladder will involve abdominal or pelvic viscera (the intestines, ureter, urinary bladder or a major blood vessel.) ~(Zakin D, Obstet Gynecol Surv 1981)or a major blood vessel.) ~(Zakin D, Obstet Gynecol Surv 1981)

Incidence and potential sequelae, contIncidence and potential sequelae, cont

9% of women who had a clinically recognised perforation, following a TOP, 9% of women who had a clinically recognised perforation, following a TOP, had a hysterectomy. This was a rate of seven per 100 000 terminations of had a hysterectomy. This was a rate of seven per 100 000 terminations of pregnancy ~ (Grimes DA , JAMA 1984, USA)pregnancy ~ (Grimes DA , JAMA 1984, USA)

Women should be warned of the possibility of uterine rupture in a future Women should be warned of the possibility of uterine rupture in a future pregnancy:pregnancy:

1. A case reported uterine rupture at 27 weeks of gestation with no history of pre-term 1. A case reported uterine rupture at 27 weeks of gestation with no history of pre-term labour, following a previous perforation and repair labour, following a previous perforation and repair

~(Tischner I,~(Tischner I, J Minim Invasive Gyaecol 2010)J Minim Invasive Gyaecol 2010)2. Cases of uterine rupture in labour have also been reported2. Cases of uterine rupture in labour have also been reported

Midwives and obstetricians should be alert for signs and symptoms of uterine Midwives and obstetricians should be alert for signs and symptoms of uterine rupture in such women, both in the second half pregnancy and in labour.rupture in such women, both in the second half pregnancy and in labour.

Perforated uterus is not an indication for elective caesarean sectionPerforated uterus is not an indication for elective caesarean section

RecognitionRecognition an injury can be suspected if:an injury can be suspected if:

1.1. extension of the instrument goes beyond the limitation of the extension of the instrument goes beyond the limitation of the uterus.uterus.

2.2. loss of resistance with further instrumentationloss of resistance with further instrumentation

3.3. Sudden loss of vision during hysteroscopic procedures due to Sudden loss of vision during hysteroscopic procedures due to collapse of the uteruscollapse of the uterus

4.4. bleeding together with a large deficit of the distension mediumbleeding together with a large deficit of the distension medium

5.5. Direct visualisation of the perforation site, omentum or bowel is Direct visualisation of the perforation site, omentum or bowel is diagnostic.diagnostic.

~ (Grimes DA , JAMA 1984, USA)~ (Grimes DA , JAMA 1984, USA)

~ (Mittal S,~ (Mittal S,. . Int J Gynaecol Obstet 1985)Int J Gynaecol Obstet 1985)

Risk factorsRisk factors

High riskHigh risk uterus and cervixuterus and cervix High risk surgeryHigh risk surgery High risk surgeonHigh risk surgeon

High risk High risk uterus and cervixuterus and cervix Perforation increases with gestation Perforation increases with gestation

and is about twice as frequent in the and is about twice as frequent in the second trimester as in the first second trimester as in the first trimestertrimester

~ (Darney PD, Obstet Gynecol 1990)~ (Darney PD, Obstet Gynecol 1990)

a small postmenopausal uterus or a small postmenopausal uterus or tight cervixtight cervix

the uterus is retroverted, acutely the uterus is retroverted, acutely anteverted or retroflexed.anteverted or retroflexed.

•Accurate estimation of gestational Accurate estimation of gestational age is therefore vitalage is therefore vital

High risk surgeryHigh risk surgery Particular surgical cases that increase the risk of uterine Particular surgical cases that increase the risk of uterine

perforation include:perforation include:

ERPC for postpartum haemorrhage ERPC for postpartum haemorrhage ((PPHPPH)) - 5.10 –5.70% - 5.10 –5.70%~(Amarin ZO, Badria LF. Arch Gynecol Obstet 2005~(Amarin ZO, Badria LF. Arch Gynecol Obstet 2005

for division of intrauterine adhesionsfor division of intrauterine adhesions~(Pridmore BR, Aust NZ J Obstet Gynaecol 1999)~(Pridmore BR, Aust NZ J Obstet Gynaecol 1999)

Elective termination of pregnancy Elective termination of pregnancy

postmenopausal bleed investigationpostmenopausal bleed investigation~ (Ben~ (Ben--Baruch G, Isr J Med Sci 1980)Baruch G, Isr J Med Sci 1980)

High risk surgeonHigh risk surgeon In the USA a five-fold increase rate of perforation has been In the USA a five-fold increase rate of perforation has been

reported by junior staffreported by junior staff

Similar results were found in Singapore where 82.5% of Similar results were found in Singapore where 82.5% of perforations were caused by junior staffperforations were caused by junior staff

~Chen LH, Singapore Med J 1995~Chen LH, Singapore Med J 1995

It was found that experience also results in the early It was found that experience also results in the early recognition of uterine injury so there is less risk of the recognition of uterine injury so there is less risk of the dangerous use of suction cannula or grasping forceps in the dangerous use of suction cannula or grasping forceps in the abdominal cavityabdominal cavity

~ (Grimes DA , JAMA 1984, USA)~ (Grimes DA , JAMA 1984, USA)

Surgeons performing surgical TOP must, Surgeons performing surgical TOP must, therefore, be adequately trainedtherefore, be adequately trained

PreventionPrevention Risk assessment:1. accurate estimation of gestational age.2. Bimanual assessment correctly identifying the size, position

adequate preparation:1. cervical preparation with prostaglandins or misoprostol -> a

reduction in cervical resistance and need for cervical dilatation (in premenopausal) no such benefit is noted in postmenopausal women

~ (RCOG guidelines on best practice in outpatient hysteroscopy

2. Adequate and gradual cervical dilatation, avoiding excessive force

Management ~TIPSManagement ~TIPS a urinary catheter should be sited. This will help to identify if there is

shock due to haemorrhage, correctly monitor fluid balance and may alert to possible bladder injury if haematuria is present

Cauterisation with diathermy during laparoscopy can also be considered for haemostasis in a small perforation.

If the original procedure remained incomplete an assistant can monitor the perforation through the laparoscope while the other experienced operator can complete the procedure, with direct visualisation to ensure that no further damage occurs.

Bowel sounds may initially still be present with bowel injury, peritonitis can take days to reveal itself clinically.

ConclusionConclusion is a rare complication but can have potentially

catastrophic consequences for women. Appropriate training with supervision, assessment of risk

factors and the use of cervical preparation can all help to reduce the risk of perforation.

Exercising caution in high risk cases should be compulsory and seeking help from senior gynaecologists as well as other specialties in a timely manner can not only help to decrease morbidity but also prevent any long-term sequelae.

Standardisation of management is vital as considerable variation between operators currently exists.