how to manage uterine perforation

1. Uterine Perforation-case based
discussion
Dr .KG Hewawitharana

2. Case
• Mrs .MH
• 48 years
• G3P3C3-all VDs & family completed + BL LRT
• Ix for peri-menopausal bleeding characterized by frequent, irregular
cycles associated with heavy menstrual loss for about 6/12
• On examination, pt had normal size uterus + cervix was healthy
• TVS-ET=20mm
• Planned for hysteroscopy + D&C

3. Surgery
• Under GA
• Lithotomy position & bladder emptied
• Uterine sound passed- anteverted, normal size ut
• Cervix dilated up to Hagar 8
• Hysteroscopy done- finding-fundal polyp
• Polyp removed & curettage done
• During this procedure-yellowish fatty tissues encountered and
procedure stopped.

4. Action
• Call for help-SR
• Patient assessed
• Decided to keep on IV AB, nil by mouth, IV fluids & planned for
diagnostic laparoscopy following day.
• Laparoscopy was done-no viscus injury other than perforated uterus
in fundal region and omental tissues entering to perforation.
• Since no active bleeding point, no further intervention was done.

5. Discussion-2013 TOG article based
• Uterine perforation is uncommon, but potentially serious
complication
• Most common reason/cause is TOP
• Uterine manipulation,ERPC,IUD insertion & Hysteroscopy are also
known causes
• Uteri that are likely for perforation in such procedure are postpartum
or pregnant uteri, atrophic uteri, anomalous uteri, Infected uteri &
retroverted uteri.

6. Incidence & sequalae
• Out patient hysteroscopy-0.002-1.7%
• Operative hysterocopy-1.6%
• 15% of IUD insertion related perforation associate with viscus damage
• 3-7.5% bowel injury noted in such instances
• Most are at uterine body & small with little bleeding
• If lower uterus or internal OS region got perforate major bleeding may
occur
• If instruments pass through damaged area, viscus or vascular damage
is high

7. When to suspect
• If instrument extend beyond the uterus with loss of resistance
• Sudden loss of vision during hysteroscopy due to collapse uterus
• Unusual bleeding with large deficit in distention medium
• Direct visualization of perforation site
• Visualization of bowel/omentum

9. Risk factors
• 1.High risk uterus & cervix
• 2.high risk surgery
• 3.High risk surgeon

10. High risk
uterus &
cervix

11. cont
• 2nd trimester surgical TOP are 2 times more likely of having
perforation than that of 1st trimester
• Thus accurate POG estimation is important to plan sx
• Also equally implicate with regard to ERPC following incomplete MC

12. High risk surgery
ERPC for retained tissues in
PPH (5%-6% cases)
When intra uterine
adhesions exist (0.07-1.8%)
TOP (0.5%)
PMB investigation with
hysteroscopy (0.2-2%)

13. High risk surgeon
• Very hard to find a gynecologist who had no experience with uterine
perforation
• Adequately trained surgeons less likely to cause perforations

14. Prevention
• Risk assessment & adequate preparation
• Risk management as explained valid consent, alert theater staff ,
keep ready laparoscope to use when necessary , get the involvement
of experienced surgeons
• Prior cervical preparation with misoprostol in premenopausal patients
to reduce resistance.(no benefit in post menopausal)
• Depend on individual scenarios, oral or vaginal PG use prior to
surgical TOP reduce dilation force, trauma & bleeding
• Adequate, gradual cervical dilation with half sized dilators avoiding
excessive force

15. cont
• Hawkins-amber Vs Hagar- former is safe and better as it needs less
force

16. cont
• USS guided procedure
• Under vision of Laparoscopy when concomitant abdominal procedure
happens

17. Management

18. cont
• Mx depend on type of procedure & instruments used for it
• If perforation is due to a dilator,curette,polyp forcep,IUD or 5mm
hysteroscope- antibiotics & observation alone sufficient
• If larger instruments used & bleeding noted-laparoscopy is needed
• If during TOP/ERPC-again laparoscopy is necessary and get the
involvement of surgeons as there may be bowel injury
• It is important to place a catheter for fluid balance monitoring & to
identify possible bladder injury if hematuria noted

19. Furthermore
• If it is a small perforation, often no intervention is required and may
use diathermy for bleeding arrest in laparoscopy
• Meanwhile if the original procedure is incomplete, under direct vision
this has to be perform, thus further injury can be avoided
• Consider laparotomy if continuing bleeding, enlarging broad ligament
hematoma, when it needs to close uterine peroration but difficult
with laparoscopy
• But try as much as possible for laparoscopic closure
• Hysterectomy is likely if identification & intervention gets delayed
because patient deteriorate with bleeding while edematous tissues
make interventions more difficult.

20. POST OP
• IV AB for 24 hrs & keep admit for 24hrs
• If stable can send home
• R/V if ny symptom
• Because-though early observation shows stable vital signs + normal
bowel sounds, subsequent symptoms of bowel injury will manifest
much later
• Document & debrief