Perforation of the uterus

Perforation of the uterus - accidental damage to the uterus, a rare but dangerous emergency obstetric condition. It occurs in about 1 out of every 250 (0.4%) cases of abortion.

The main symptoms are: abdominal pain, severe vaginal bleeding, bloating, nausea, vomiting, chills, fever and heart palpitations. The ultrasound is used to confirm the diagnosis.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]

Causes of the perforation of the uterus

Among the causes of intra-abdominal hemorrhage, a certain place is taken by the perforation of the uterus during medical manipulations in its cavity. Most often this occurs in the manufacture of artificial abortion and the removal of the remains of the fetal egg in women with spontaneous or criminal miscarriage, but uterine perforation can occur with diagnostic curettage of the uterine mucosa, hysteroscopy, intrauterine contraceptive.

Artificial abortion is the most frequent gynecological operation. Despite the seeming simplicity and speed of execution, it carries a great danger, which is well known to experienced professionals and young beginners forget. Perforation of the uterine wall refers to one of the most serious complications of this operation. The frequency of perforation of the uterus ranges from 0.03 to 0.5%. At present, these figures have not only not decreased, but even slightly increased. Completely eliminate this complication, apparently, it is impossible. Increasing the qualification of a doctor, clearly limiting the time of pregnancy, choosing the most rational intervention technique, one can not influence such risk factors as the age of a woman, previous diseases of the reproductive apparatus, uterine hypoplasia, fibroids, malformations, etc. Recognition of the leading role of morphological changes in the tissues of the wall the uterus should not soothe the doctor, disarm him before the fatal inevitability of such a complication. On the contrary, it must mobilize the attention of the operating person before each intra-uterine intervention. If the injury can not be prevented, the maximum concentration helps the doctor to recognize it in a timely manner.

Perforation of the uterus can occur at any stage of the operation: when probing the uterus, expanding the cervical canal, emptying the cavity. There are uncomplicated perforations (without damage to neighboring organs) and complicated (with injuries of the intestine, omentum, bladder, uterine appendages, etc.).

Uterine perforations produced by the uterine probe rarely occur (2-5%), represent the least danger, as they are usually not accompanied by heavy bleeding and injuries to adjacent organs. Hegard extender is applied a few times (5-15%), the perforation is usually located in the supra -inal part of the cervix, the isthmus and the lower body of the uterus. In this case, intra-abdominal bleeding or hematoma between the broad ligament sheets is much more often observed. The perforation of the wall by the expander of Geghar contributes to excessive bending of the uterus body anteriorly or posteriorly, on which the doctor did not fix attention. Rough and hasty dilatation of the cervical canal without the use of all the numbers of dilators, even without leading to perforation of the uterus, can contribute to the trauma of the muscular layer in the region of the internal pharynx. Internal pharyngeal cancers can be accompanied by significant bleeding from the cervical canal or lead to unfavorable long-term consequences - the formation of isthmico-cervical insufficiency.

The most frequent (80-90%) and dangerous perforations of the uterus lead to manipulation of the curette and abortion. In this case, the perforation is usually located in the upper part of the uterus (the bottom, anterior, posterior and lateral walls), the wound can be of considerable size and accompanied by heavy bleeding. The greatest danger in perforating the uterus curette and especially abortion is the trauma of the abdominal cavity.

[12], [13], [14], [15], [16], [17], [18], [19], [20], [21]

Complications and consequences

The danger of perforating the uterus multiplies many times, if this complication is not recognized in time. Meanwhile, the attentive attitude of the doctor to all manipulations during the abortion almost completely excludes the possibility of not noticing the perforation of the wall or its consequences.

Complications include inflammation of the abdominal lining (peritonitis), intestinal or bladder trauma, massive bleeding (hemorrhage) and infection (sepsis).

[22], [23], [24], [25], [26], [27]

Diagnostics of the perforation of the uterus

On the perforation of the uterus should be thought in those cases when the instrument suddenly goes to great depth, as it were, fails, without meeting the resistance of the uterine wall. At this moment it is strongly recommended to suspend all manipulations, "freeze", without removing the instrument from the uterus, and try to probe through its abdominal wall to probe its end. This simple action helps diagnose perforation in almost all cases. If the operation of abortion is performed under local or conduction anesthesia, then the sudden percutaneous pain indicates the possibility of perforating the uterus. Complicated cases are sometimes recognized by removal from the uterus of the omentum, loops of the intestine, ovary, etc. Finally, careful monitoring of the medical staff for the condition of the woman during the first hours of the postoperative period helps to suspect a trauma of the uterus that was not recognized at the time of the abortion. Signs of increasing internal bleeding or peritoneal symptoms cause the doctor to make an appropriate examination and put the correct diagnosis.

In all cases of perforation of the uterus during abortion, there is shown abdominal, thorough examination of all parts of the uterus and revision of the adjacent organs of the small pelvis and intestine. If a small defect in the uterine wall is detected, the volume of the operation is limited to suturing the wound after excision of its edges. Beforehand, through the perforation, it is necessary to scrack the mucous membrane of the uterine wall to prevent the remaining parts of the fetal egg.

In the presence of large or multiple defects of the wall with damage to the vascular bundles, with the formation of hematomas in the parametric fiber, it is necessary to perform a supravaginal amputation, and in some cases - extirpation of the uterus. The volume of surgery is also extended in cases where uterine damage occurs in women with fibroids or adenomyomas.

In the case of complicated perforation of the uterus, the operating gynecologist may face minor damage to the bladder, intestine, omentum, with which he can cope on his own. However, having found extensive injuries of adjacent organs of the pelvis or abdominal cavity, the gynecologist must resort to the help of appropriate specialists.

As often happens in the practice of a doctor, extreme situations, especially of iatrogenic origin, are easier to prevent than to eliminate their consequences. Perforation of the uterus is not an exception to this rule.

To prevent the trauma of the uterus during the performance of an induced abortion, it is necessary:

• Do not perform surgery for gestational periods exceeding 12 weeks;
• be sure to perform bimanual examination immediately before the intervention for precise orientation in the size and position of the uterus;
• always impose bullet forceps on the front and back lips of the cervix: this simple technique when lowering the neck ensures the straightening of the angle between her and the body of the uterus;
• in no case should we neglect the careful probing by means of which the length of the uterine cavity and the direction of the cervical canal are determined;
• Carefully produce an enlargement of the cervical canal: up to an 8-week gestation period it is desirable to use a vibrodilator; expanders of Gegar to introduce in strict accordance with the numbering; stiff neck must be prepared by the preliminary administration of antispasmodics or prostaglandins;
• evacuation of the fetal egg with a gestation period not exceeding 8 weeks, it is desirable to carry out by vacuum suction; in some cases, act as a curette, and use aborttsang only to remove the exfoliated parts;
• to perform an operation under adequate anesthesia, not only in the interests of women, but also in order to create favorable conditions for the doctor's work.

Perforation of the uterus can occur during a diagnostic curettage, performed in connection with the suspected malignant tumor. With a deep lesion of the muscle layer by the cancer process, perforation takes place without the special effort of the operating one. For better orientation in the state of the uterine cavity, diagnostic hiccups should preferably be preceded by hysterography or hysteroscopy. The information obtained will allow to take the scraping of the tissue sighting, with the utmost care and, not least, ablastically.

Perforation of the uterus can be a complication of intrauterine contraception. Most often, the eye occurs immediately at the time of injection of IUD, especially if it is produced immediately after the abortion. However, perforation of the uterine wall can occur spontaneously. According to different authors, the frequency of perforations varies widely and depends on the shape of the contraceptive. The frequency of uterine perforations is largely determined by the qualification of the doctor.

The perforation of the uterus, even produced at the time of IMC administration, is not always easy to recognize. There are so-called mute perforations, which are not immediately apparent. It is even more difficult to diagnose spontaneous or secondary perforation.

The doctor is obliged to think about the possibility of perforation of the uterus, if during the introduction of IUD, the woman feels a sharp pain. It is possible to assume the possibility of this complication even in cases when severe cramping pains, not stopping, last for several days after the introduction of IUD. Secondary perforation can be suspected if the woman complains of constant unsharp pain in the lower abdomen, while she did not notice the spiral expulsion, and the doctor does not detect the IUD strands in the vagina.

Expressed clinical signs of internal bleeding are found infrequently. Symptoms of limited or diffuse peritonitis appear rather late. Internal gynecological examination will not give clear evidence in favor of the perforation. Therefore, modern hardware diagnostic methods are of paramount importance: ultrasound, hysteroscopy and laparoscopy.

Accurate diagnosis of complete and incomplete perforation of the uterus of the IUD can be carried out using ultrasound. Incomplete perforation of the uterus is better defined in the II phase, the menstrual cycle, when the middle uterine echo is clearly revealed. The output of IUD beyond the M-echo indicates incomplete uterine perforation. On the full perforation says the location of the contraceptive outside the uterus.

Confirming the penetration of IUD into the abdominal cavity, it is necessary to start surgical removal of it. "During the operation, the uterus is carefully inspected and, depending on the detected changes, the issue of removing or preserving it is decided. Early diagnosis of uterine perforation and timely surgical intervention ensure the preservation of the uterus. Long stay of IUD in the abdominal cavity leads to pressure sores, development of inflammatory and adhesive process, intestinal obstruction. Necrotic and inflammatory changes in the uterine wall are a direct indication of its removal.

[28], [29], [30], [31], [32], [33], [34], [35], [36]

Forecast

If the cause of the perforation is known and the treatment started on time, the prognosis is favorable.

[37], [38], [39], [40], [41]