Key content
Uterine perforation is an uncommon but potentially serious
complication of uterine manipulation, evacuation of retained
products of conception or termination of pregnancy (TOP),
hysteroscopic procedures and during coil insertion.
Factors that increase the risk of uterine perforation include uterine
anomalies, infection, recent pregnancy and postmenopause. TOP is
the most common procedure associated with uterine perforation.
Prevention of uterine perforation is favoured, although if it occurs,
initial recognition together with immediate and ongoing
management is key to reducing morbidity, mortality and
long-term consequences.
It is important that surgeons performing surgical TOP are
adequately trained. The experience of the surgeon results not only
in fewer perforations but also in the early recognition of uterine
injury.
Uterine perforation is a complication that is well recognised by all
gynaecologists, although subsequent assessment and management
needs to be standardised.
Learning objectives
To be aware of the incidence of uterine perforation and the
potential serious complications that can result.
To identify the risk factors of uterine perforation, the
mechanism of injury and how to potentially prevent it from
occurring.
To increase awareness of this complication and to propose a
standardised management protocol if a uterine perforation occurs,
together with risk management issues.
Ethical issues
Are women at increased risk of uterine perforation
counselled adequately about the complications and
consequences?
Are women at increased risk given the full range of alternative
treatment options?
Keywords: complications / prevention / risk factors / risk
management points / uterine perforation.
Introduction
Uterine perforation is an uncommon but potentially serious
complication of uterine manipulation, evacuation of
retained products of conception (ERPC), termination of
pregnancy (TOP), hysteroscopic procedures and during
coil insertion.
Factors that increase the risk of uterine perforation include
uterine anomalies, infection, recent pregnancy and
postmenopause. TOP is the most common procedure
associated with uterine perforation.1
Uterine perforation can cause severe morbidity and even
mortality, however, prompt recognition and management
can improve clinical outcomes. It is a complication that is
well recognised by all gynaecologists, although subsequent
assessment and management needs to be standardised.
Incidence and potential sequelae
Guidance from the Royal College of Obstetricians and
Gynaecologists (RCOG) on best practice in outpatient
hysteroscopy2 suggests an average incidence of perforation
of 0.002–1.7%. With hysteroscopic surgery the incidence of
uterine perforation has been reported at 1.6%.3
Most perforations are in the body of the uterus and are
often small, tending to cause relatively little haemorrhage.
However, perforations at the internal cervical os and lower
part of the uterus are more serious as they are often lateral
and can involve branches of the uterine vessels. This can lead
to haematoma formation in the broad ligament or serious
intra-peritoneal haemorrhage.
Common sites of uterine perforation and their incidence6
Site of perforation Incidence%
Anterior wall 40
Cervical canal 36
Right lateral wall 21
Left lateral wall 17
Posterior wall 13
Fundus 13
Table 2. Incidence of uterine perforation with the use of various
instruments9
Instrument Incidence of perforation%
Suction cannula 51.3
Hegar dilator 24.4
Curette 16.2
Uterine and cervical factors that increase the risk of perforation
Advanced gestation when TOP is performed
ERPC for postpartum haemorrhage
Parous uterus
Recent pregnancy in the past 6 months
Small postmenopausal uterus
Tight postmenopausal cervix
Uterine cavity distorted by fibroids
Intrauterine synechiae or adhesions
Pyometra
Infection
Position and attitude of the uterus
Retroverted, acutely anteverted or retroflexed uterus
Uterine anomalies
The scarred uterus (previous uterine surgery)
Management
Management of uterine perforation will depend on the
procedure being carried out and on the instruments used. If a
perforation occurs when using a dilator, up to 5 mm
hysteroscope, curette, during coil insertion, or polyp
forceps, then antibiotics, observation and explanation to
the patient is all that is necessary. If larger diameter
instruments are used, tissues grasped and avulsion
attempted, or if there is significant revealed bleeding from
a uterine tear, then laparoscopy should be performed.
A perforation that has been identified and made during the
use of an activated resection loop or laser fiber or during a
TOP or ERPC should prompt a laparoscopy. In these cases
consultation with a general surgeon should be considered, as
bowel injury may be a possibility.
If a laparoscopy is to be performed, then 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.
Small perforations with little associated bleeding do not
require repair. 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.
A laparotomy should be considered when during a
laparoscopy, continual haemorrhage occurs or if there is an enlarging broad ligament haematoma. If a uterine perforation
is large enough to require suturing, this should be performed
laparoscopically. If the surgeon is unable to do this themselves,
then they should seek help from a laparoscopic surgeon. A
laparotomy may have to be performed if the surgeon is unable
to suture laparoscopically and is unable to find a colleague who
can. Early assistance should be sought from a general/colorectal
surgeon or urologist if suspected bowel or urinary tract injury
has occurred. They, in turn, may decide to perform a
laparoscopy or laparotomy depending on the extent of the
suspected injury.
Gynaecologists will generally repair the defect in the uterus
caused by the perforation and several suture materials can be
used according to individual preference. However, in a few
cases the injury will be so severe that hysterectomy is
necessary. Hysterectomy is more likely if the surgeon was
inexperienced and if there was a delay in performing a
laparoscopy or laparotomy. This is generally because
traumatised tissues rapidly become oedematous with
dissection being impeded by extensive expanding
haematoma. In addition, the condition of the patient has
generally deteriorated by now because of inadequate blood
volume replacement.
Women whose injury occurred in a day unit or small
independent sector hospital should be assessed, resuscitated
and transferred for specialist care rather than undergo a
laparoscopy on site. It is therefore vital that all units have
arrangements in place for immediate consultant advice and
transfer to hospital when such emergencies occur.
Following a uterine perforation and any associated
injuries, admittance to hospital, intravenous antibiotics
and close observation is necessary. Over the following
24 hours, temperature, blood pressure and bowel sounds
must be monitored. Bowel sounds may initially still be
present with bowel injury, peritonitis can take days to reveal
itself clinically. Patients should be discharged after 24 hours
if asymptomatic with instructions to return if any
symptoms develop.
Conclusion
Uterine perforation is a rare complication but can have
potentially catastrophic consequences for women. It can be
associated with severe morbidity. 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.