The document discusses uterine perforation, a potential complication of various gynecological procedures. It notes that termination of pregnancy is the most common associated procedure. Risk factors include uterine anomalies, infection, recent pregnancy, and postmenopause. Most perforations occur in the uterine body and cause little bleeding, but some can involve other organs. Prevention focuses on risk assessment, cervical preparation, and gradual dilation. Management tips include urinary catheterization, cauterization, and seeking help from senior physicians. Overall, uterine perforation is rare but can have serious consequences, so appropriate training and caution are important.

1. The perforated
uterus ~Review
Hashem Yaseen ,MDHashem Yaseen ,MD
33rdrd
year OG resident KAUHyear OG resident KAUH

2. IntroductionIntroduction
 Uterine perforation is an uncommon but
potentially serious complication of:
1.1. uterine manipulationuterine manipulation
2.2. 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 insertion
5.5. hysteroscopic procedureshysteroscopic procedures
 Factors that increase the risk of uterine perforation
include:
1.1. uterine anomalies,uterine anomalies,
2.2. infection,infection,
3.3. recent pregnancyrecent 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)

3. Incidence and potential sequelaeIncidence and potential sequelae
 With hysteroscopic surgery the incidence of uterine perforation has beenWith hysteroscopic surgery the incidence of uterine perforation has been
reported at 1.6%. ~ (RCOG)reported at 1.6%. ~ (RCOG)
 Most perforations areMost perforations are in the bodyin the body of the uterus and are often small, tending toof 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 uterineinternal 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 deviceUp to 15% of uterine perforations caused by the fitting of an intrauterine device
will involve abdominal or pelvic viscera (the intestines, ureter, urinary bladderwill 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)

4. 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 ofhad 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 futureWomen 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-term1. A case reported uterine rupture at 27 weeks of gestation with no history of pre-term
labour, following a previous perforation and repairlabour, 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 uterineMidwives 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

5. RecognitionRecognition
 an injury can be suspected if:an injury can be suspected if:
1.1. extension of the instrument goes beyond the limitation of theextension 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 toSudden 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 isDirect visualisation of the perforation site, omentum or bowel is
diagnostic.diagnostic.

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

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

8. Risk factorsRisk factors
High riskHigh risk
uterus and cervixuterus and cervix
High risk surgeryHigh risk surgery High risk surgeonHigh risk surgeon

9. High riskHigh risk
uterus and cervixuterus and cervix
 Perforation increases with gestationPerforation increases with gestation
and is about twice as frequent in theand is about twice as frequent in the
second trimester as in the firstsecond trimester as in the first
trimestertrimester
~ (Darney PD, Obstet Gynecol 1990)~ (Darney PD, Obstet Gynecol 1990)
 a small postmenopausal uterus ora small postmenopausal uterus or
tight cervixtight cervix
 the uterus is retroverted, acutelythe uterus is retroverted, acutely
anteverted or retroflexed.anteverted or retroflexed.
•Accurate estimation of gestationalAccurate estimation of gestational
age is therefore vitalage is therefore vital

10. High risk surgeryHigh risk surgery
 Particular surgical cases that increase the risk of uterineParticular surgical cases that increase the risk of uterine
perforation include:perforation include:
 ERPC for postpartum haemorrhageERPC 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 pregnancyElective termination of pregnancy
 postmenopausal bleed investigationpostmenopausal bleed investigation
~ (Ben~ (Ben--Baruch G, Isr J Med Sci 1980)Baruch G, Isr J Med Sci 1980)

11. High risk surgeonHigh risk surgeon
 In the USA a five-fold increase rate of perforation has beenIn 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% ofSimilar 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 earlyIt was found that experience also results in the early
recognition of uterine injury so there is less risk of therecognition of uterine injury so there is less risk of the
dangerous use of suction cannula or grasping forceps in thedangerous 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

12. 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

14. 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.

15. 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.