The perforated uterus

Abstract

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?

Authors’ reply

“…If however, avulsion is attempted then a laparoscopy should be performed. Both these points are clearly highlighted in the ‘Management’ section of our article and in Figure 1 …”

“…We are not stating that TOP has the highest incidence of perforation. Indeed if one reads the ‘High risk surgery’ section of our article, the incidence associated with each procedure is described, and we acknowledge in this section that surgical TOP does not have the highest incidence …”

A large amniocele through a fundal uterine defect diagnosed on 2D ultrasound imaging

“…Some of these cases are even performed by untrained personnel such as Nurses, Midwives, and community health extension workers (CHEW) in Nigeria [20]. Early identification and diagnosis of uterine perforation and subsequent management will significantly reduce morbidity, longterm sequelae and even mortality [21].…”

Re: The perforated uterus

“…In the England and Wales 2012 statistics for TOP, 96 263 surgical TOPs were performed. 1 We are not stating that TOP has the highest incidence of perforation. Indeed if one reads the 'High risk surgery' section of our article, the incidence associated with each procedure is described, and we acknowledge in this section that surgical TOP does not have the highest incidence.…”

“…We read with great interest the article on the perforated uterus by Shakir and Diab published recently. 1 We have several comments to make about this paper. First, the authors state that termination of pregnancy is the most common procedure associated with uterine perforation.…”