Uterine perforation during gynecologic procedures
- Barbara S Levy, MD, FACOG
Barbara S Levy, MD, FACOG
- Vice President for Health Policy
- American College of Obstetricians & Gynecologists
Uterine perforation is a potential complication of all intrauterine procedures and may be associated with injury to surrounding blood vessels or viscera (bladder, bowel) [1,2]. In addition, uterine perforation and associated complications can result in hemorrhage or sepsis. The risk of uterine perforation is increased by factors that make access to the endometrial cavity difficult (eg, cervical stenosis) or alter the strength of the myometrial wall (eg, pregnancy, lactation, and menopause).
The prevention, diagnosis, and management of uterine perforation during gynecologic procedures will be reviewed here. Other complications of uterine surgery are discussed separately. (See "Complications of gynecologic surgery" and "Overview of hysteroscopy" and "Overview of pregnancy termination".)
Uterine perforation — The incidence of uterine perforation is generally based upon self-report by surgeons. In addition, many perforations are not recognized or confirmed, so it is likely that any reported incidence is an underestimate.
In most studies, hysteroscopy is complicated by confirmed uterine perforation in approximately 1 percent of operative procedures. There are fewer perforations during diagnostic hysteroscopy. (See "Overview of hysteroscopy", section on 'Uterine perforation'.)
During dilation and curettage for disorders not related to pregnancy, perforation has been reported in approximately 0.3 percent of premenopausal patients and 2.6 percent in the postmenopausal patients. (See "Dilation and curettage", section on 'Uterine perforation'.)
- Gentile GP, Siegler AM. Inadvertent intestinal biopsy during laparoscopy and hysteroscopy: a report of two cases. Fertil Steril 1981; 36:402.
- Sullivan B, Kenney P, Seibel M. Hysteroscopic resection of fibroid with thermal injury to sigmoid. Obstet Gynecol 1992; 80:546.
- Aydeniz B, Gruber IV, Schauf B, et al. A multicenter survey of complications associated with 21,676 operative hysteroscopies. Eur J Obstet Gynecol Reprod Biol 2002; 104:160.
- Agostini A, Cravello L, Bretelle F, et al. Risk of uterine perforation during hysteroscopic surgery. J Am Assoc Gynecol Laparosc 2002; 9:264.
- Jansen FW, Vredevoogd CB, van Ulzen K, et al. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol 2000; 96:266.
- Shveiky D, Rojansky N, Revel A, et al. Complications of hysteroscopic surgery: "Beyond the learning curve". J Minim Invasive Gynecol 2007; 14:218.
- Hulka JF, Peterson HB, Phillips JM, Surrey MW. Operative hysteroscopy. American Association of Gynecologic Laparoscopists 1991 membership survey. J Reprod Med 1993; 38:572.
- Ben-Baruch G, Menczer J, Shalev J, et al. Uterine perforation during curettage: perforation rates and postperforation management. Isr J Med Sci 1980; 16:821.
- Grossman D, Blanchard K, Blumenthal P. Complications after second trimester surgical and medical abortion. Reprod Health Matters 2008; 16:173.
- Allen RH, Goldberg AB, Board of Society of Family Planning. Cervical dilation before first-trimester surgical abortion (<14 weeks' gestation). SFP Guideline 20071. Contraception 2007; 76:139.
- Amarin ZO, Badria LF. A survey of uterine perforation following dilatation and curettage or evacuation of retained products of conception. Arch Gynecol Obstet 2005; 271:203.
- Paschopoulos M, Polyzos NP, Lavasidis LG, et al. Safety issues of hysteroscopic surgery. Ann N Y Acad Sci 2006; 1092:229.
- Phillips DR, Nathanson HG, Milim SJ, Haselkorn JS. The effect of dilute vasopressin solution on the force needed for cervical dilatation: a randomized controlled trial. Obstet Gynecol 1997; 89:507.
- Hobo R, Netsu S, Koyasu Y, Tsutsumi O. Bradycardia and cardiac arrest caused by intramyometrial injection of vasopressin during a laparoscopically assisted myomectomy. Obstet Gynecol 2009; 113:484.
- Istre O. Managing bleeding, fluid absorption and uterine perforation at hysteroscopy. Best Pract Res Clin Obstet Gynaecol 2009; 23:619.
- Hefler L, Lemach A, Seebacher V, et al. The intraoperative complication rate of nonobstetric dilation and curettage. Obstet Gynecol 2009; 113:1268.
- Darney PD, Atkinson E, Hirabayashi K. Uterine perforation during second-trimester abortion by cervical dilation and instrumental extraction: a review of 15 cases. Obstet Gynecol 1990; 75:441.
- Shulman SG, Bell CL, Hampf FE. Uterine perforation and small bowel incarceration: sonographic and surgical findings. Emerg Radiol 2006; 13:43.
- Leibner EC. Delayed presentation of uterine perforation. Ann Emerg Med 1995; 26:643.
- Sentilhes L, Sergent F, Berthier A, et al. [Uterine rupture following operative hysteroscopy]. Gynecol Obstet Fertil 2006; 34:1064.
- Sentilhes L, Sergent F, Roman H, et al. Late complications of operative hysteroscopy: predicting patients at risk of uterine rupture during subsequent pregnancy. Eur J Obstet Gynecol Reprod Biol 2005; 120:134.
- Kerimis P, Zolti M, Sinwany G, et al. Uterine rupture after hysteroscopic resection of uterine septum. Fertil Steril 2002; 77:618.
- Uterine perforation
- Associated hemorrhage or visceral injury
- RISK FACTORS
- Pre-procedure preparation
- - Informed consent
- - Pre-procedure evaluation
- - Cervical preparation
- - Treatment of vaginal atrophy
- Preventive measures during the procedure
- - Uterine position
- - Difficult cervical dilation
- Safe use of operative instruments
- PERIOPERATIVE PRESENTATION OF UTERINE PERFORATION
- - During the procedure
- - Post-procedure clinical manifestations
- - Evaluation
- - Candidates for observation
- - Criteria for surgical management
- - Abdominal exploration
- - Completing the original procedure
- Post-procedure monitoring
- DELAYED PRESENTATION
- EFFECTS ON FUTURE REPRODUCTION
- SUMMARY AND RECOMMENDATIONS