UTERINE PERFORATION: CAUSES AND TREATMENT.
Uterine perforation refers to iatrogenic complications, that is, its occurrence to one degree or another occurs due to the fault of medical workers.
UTERINE PERFORATION: WHAT IS IT
Perforation of the uterus is a through damage to its wall with surgical instruments when performing intrauterine interventions. Complication occurs in 0.03 – 1% of cases of intrauterine procedures, but in recent years there has been a tendency to increase the percentage of pathology, which is explained by the expansion of diagnostic intrauterine methods and the increase in the number of diseases of the female genital organs.
The most dangerous case of uterine perforation is damage to the organ wall by a curette (sharp edges of the instrument) or abortion (during abortion), which is fraught with the capture of abdominal organs and their removal into the uterine cavity.
Perforation of the fetus can occur at any stage of the operation, including its sounding, expansion of the cervical canal, curettage of the walls of the organ, and extraction of tissues of the ovum.
Complication can be complete when the entire thickness of the uterine wall is damaged and incomplete (perforation reaches the serous membrane, but does not damage it). Complete perforation of the uterus is complicated (damage to the pelvic organs: large intestine, bladder, ovaries, omentum) and uncomplicated (abdominal organs are not damaged).
Perforation of the uterine wall is considered a formidable surgical complication and can lead to massive bleeding, peritonitis, and if untimely medical care is fatal.
REASONS AND RISK FACTORS
The organ is injured during the manipulation performed in its cavity. Most often, uterine perforation is performed during the surgical termination of pregnancy. Despite the presence of predisposing factors in the patient, the complication is due to a violation of the production technique of the intrauterine procedure and / or the rude actions of the operating gynecologist. Perforation of the uterus can also be performed by removing a frozen pregnancy (often after 12 weeks) and the remains of the ovum, diagnostic curettage, during hysteroscopy and intrauterine excision of myomatous nodes or polyps, hysterography, dissection of intrauterine adhesions (Asherman’s syndrome), during laser uterine recovery cavity, the introduction of an intrauterine device.
Percentage of uterine perforation during surgical abortion:
- organ sensing (2 – 5%);
- dilatation (expansion) of the cervical canal (5 – 15%);
- curettage (curettage) or extraction of the fetal parts with an abortzang (reaches 90%).
It is characteristic that a uterine puncture with a probe is not so dangerous as a rough expansion of the cervical canal with metal dilators, which can be accompanied by ruptures of the cervix, perforation of the isthmus and lower uterine segment. If the wall of the organ is damaged by a curette or abortion, the dimensions of the perforated hole are quite serious, which causes massive bleeding and further damage to the internal organs.
The following factors suggest the occurrence of complications:
- bending the uterus posteriorly or bending the organ anteriorly;
- acute and chronic endometritis;
- fibromyoma or (especially) uterine cancer;
- existing scar on the uterus (after cesarean section, conservative myomectomy);
- age-related involution of the uterus (reduction of its size after 50); interruption of gestation in the period of 12 weeks or more;
- criminal abortion;
- rude and fussy actions of the doctor; low qualification of a specialist;
- underdevelopment of the body or its malformations;
- numerous curettage of the organ;
- lack of visual control (ultrasound or hysteroscopy).
UTERINE PERFORATION SYMPTOMS
The clinical picture of the complication is determined by its nature (complete or incomplete perforation of the organ wall, wound and / or removal of the abdomen in the uterine cavity) and the location of the perforated hole. With incomplete perforation of the fetus or covering the puncture site with some organ (most often the perforated opening is closed with an omentum), pathological symptoms are absent or weakly expressed.
Suspicion of uterine perforation allows the occurrence of sharp, dagger pain in the lower abdomen during intrauterine manipulation and the preservation of severe pain after the procedure. Also, the doctor should be warned by the appearance of profuse blood discharge from the uterus during and / or after the operation, increasing weakness, lethargy and dizziness. A significant outflow of blood into the abdominal cavity is accompanied by pallor of the skin and mucous membranes, increased heart rate, hypotension, tension of the abdominal muscles and the appearance of peritoneal symptoms.
WHAT COMPLICATION IS EXTREMELY
Untimely detected perforation of the uterus threatens with serious complications, which can subsequently affect the reproductive function of the patient.
Early complications of pathology include:
- intestinal injury;
- damage to the bladder;
- massive intra-abdominal bleeding;
- the formation of hematomas between the leaves of the ligament of the uterus, under its serous membrane;
- peritonitis, passing into sepsis.
Long-term complications include:
- the formation of ICN (damage to the muscle layer of cervix);
- the formation of intrauterine adhesions;
- Infertility due to the development of Asherman syndrome or hysterectomy.
The possible perforation of the uterine wall during the implementation of the intrauterine procedure is indicated by a sign of immersion of the instrument more than the estimated depth, the sensation of its “failure”. In this case, it is necessary to palpate the front wall of the abdomen without removing the instrument from the uterus to determine its end in the abdominal cavity. The complicated perforation is evidenced by the extraction from the cavity of the organ of the intestinal loop, ovary or omentum (most often).
During the installation of the IUD, perforation of the wall of the fetus is indicated by the disappearance of the contraceptive threads from the cervical canal, and during visualization their attempt to remove the intrauterine device by pulling on the “antennae” is unsuccessful, while the patient feels a sharp pain, and the doctor has resistance. If the uterine wall is injured during hysteroscopy, the doctor notes that it is impossible to maintain a stable pressure in the organ cavity, there is no outflow of fluid poured into its cavity, intestinal loops and other contents of the small pelvis are visualized on the monitor screen.
If there is a suspicion of uterine perforation, but the absence of reliable signs of a complication or a sharp deterioration in a woman’s condition, she is transferred to a ward under the supervision of medical personnel to further determine the patient’s management tactics. With a satisfactory condition of the woman, pelvic ultrasound is performed with a vaginal sensor. The complication is indicated by the presence of free fluid in the pelvic cavity and the perforation hole in the organ wall.
UTERINE PERFORATION TREATMENT
The management of the patient with a complication arises is determined by the time of diagnosis, the size, location and mechanism of the injury (abortion, curettage of the organ or installation of the IUD) and the trauma of neighboring organs. It is extremely rare that conservative management of the patient with the appointment of bed rest, cold to the lower abdomen, contractile and antibacterial drugs is possible.
Indications for conservative therapy:
- incomplete perforation of the uterine wall;
- the absence of trauma to the abdominal organs;
- the absence of a hematoma in the perinatal fiber;
- intra-abdominal bleeding did not occur.
The choice of conservative-observational tactics should be confirmed by transvaginal ultrasound with subsequent dynamic control.
All other cases of perforation of the fetus are subject to surgical intervention, before which intensive preoperative preparation is carried out: infusion therapy (according to the indications of blood transfusion), stabilization of blood pressure (glucocorticoids), hemostatics, uterotonics.
The volume of surgery depends on the number of perforations, their size, damage to large uterine vessels and neighboring organs. With a small defect from the uterine wall and the absence of bleeding, it is sutured with a preliminary curettage of the uterine cavity through the perforated hole (when installing the IUD and organ perforation, the contraceptive is removed from the defect or pelvic cavity). Indications for supravaginal amputation of the uterus are multiple defects or one, but a large rupture of the uterine wall, wound of the uterine artery. With damage to the isthmus or lower segment of the uterus, gynecologists tend to extirpate the uterus. When injuring the intestines or bladder, their injuries are sutured, and abdominal surgeon performs advanced operations on the abdominal organs. In the postoperative period, antibiotics, uterotonics, infusion therapy are prescribed.
FORECAST AND PREVENTION
Timely diagnosis and surgical intervention for uterine perforation provides a favorable prognosis. Subsequently, problems may arise in relation to conception and bearing a pregnancy. Prevention of perforation of the organ includes compliance with the technique and phased production of intrauterine manipulations, including the introduction of an IUD, the introduction of instruments into the uterine cavity with caution, visual control of all intrauterine interventions (ultrasound at the end of the procedure, hysteroscopy during it). Women are advised to abandon abortions, plan a pregnancy, regularly visit a gynecologist and treat inflammatory processes of the genital organs.