The perforated uterus - TOG article

Question 1

Which factors increase the risk of uterine perforation?

Answer 1

Uterine anomalies
Infection
Recent pregnancy
Post-menopause

Question 2

What is the incidence of uterine perforation during hysteroscopy and hysteroscopic surgery?

Answer 2

Hysteroscopy 0.002-1.7%

Surgery 1.6%

Question 3

Where do most perforations occur?

Answer 3

Anterior wall of the uterus (40%)
Cervical canal (36%)
Right lateral Wall (21%)
Left lateral wall (17%)
Posterior wall, fundus (13%)

Question 4

Where do the most serious perforations occur?

Answer 4

Internal os/lower part of the uterus - often lateral and can involve branches of the uterine vessels

Question 5

How many uterine perforations caused by IUD fitting will involve abdominopelvic viscera (and specifically, bowel)?

Answer 5

Up to 15%

Bowel injury - 3-7.5%

Question 6

In the USA how many women with a clinically recognised perforation following a TOP had a hysterectomy?

Answer 6

9%

Rate of 7/100,000

Question 7

What are the signs of uterine perforation?

Answer 7

Extension of instrument beyond limitation of uterus
Loss of resistance
Sudden loss of vision during hysteroscopy and distension medium deficit
Direct visualisation of intraabdominal organs

Question 8

What is the most likely instrument to cause uterine perforation?

Answer 8

Suction cannula 50%
Hegar dilator 25%
Curette 15%

Question 9

Which procedure carries the highest risk of uterine perforation?

Answer 9

Surgical TOP
Increases with gestation (x2 2nd trimester as 1st)
ERPC following PPH also risky

Question 10

What is the management of uterine perforation if occured using dilators, <5mm hysteroscopy, curette, coil insertion, polyp forceps?

Answer 10

Admit, IV antibiotics, observation and explanation
Incident form
Inform GP

Question 11

When should a laparoscopy be performed when a uterine perforation is suspected?

Answer 11

Larger diameter instruments
Tissues grasped/avulsion attempted
Significan revealed bleeding
Activated resection loop/laser fibre
During TOP/ERPC

Question 12

What is the management of uterine perforation with laparoscopy?

Answer 12

Consider consulting general surgeon
Urinary catheter
Cauterisation with diathermy if small perforation
Direct visualisation to complete the procedure

Question 13

When should laparotomy be considered with uterine perforation?

Answer 13

Continual haemorrhage

Enlarging broad ligament haematoma

Question 14

When is a hysterectomy more likely when a uterine perforation occurs?

Answer 14

Inexperienced surgeon

Delay in performing laparoscopy/laparotomy