The perforated uterus

M R C O G PA R T 2 · S O S P O C K E T C A R D · K N O W L E D G E A R E A 3 – C O R E S U R G I C A L S K I L L S

The Perforated Uterus Shakir F, Diab Y. The perforated uterus. TOG 2013;15:256–261. doi:10.1111/tog.12056

0.002–1.7% 40% 51.3% PERFORATION INCIDENCE (OUTPATIENT PERFORATIONS AT ANTERIOR WALL PERFORATIONS CAUSED BY SUCTION HYSTEROSCOPY) (COMMONEST SITE) CANNULA

DO N' T-M IS S FA C TS

  1. TOP is the commonest cause of uterine perforation; risk doubles in the 2nd trimester vs 1st trimester

  2. Commonest site: anterior wall (40%); commonest instrument: suction cannula (51.3%)

  3. Up to 15% of IUD perforations involve pelvic/abdominal viscera; bowel injury in 3–7.5%

  4. Small instrument, no bleeding → antibiotics + observation only. Large instrument/avulsion/significant bleeding/energy device/TOP-ERPC perforation → laparoscopy ± general surgeon

  5. Site a urinary catheter before laparoscopy – detects shock, monitors fluids, flags bladder injury

  6. Laparotomy if continual haemorrhage/enlarging broad ligament haematoma at laparoscopy, or if laparoscopic suture unavailable

  7. Warn women of future uterine rupture risk in pregnancy/labour – disclose perforation history to obstetrician; case report of rupture at 27 weeks with no labour

  8. Post-injury: monitor temp/BP/bowel sounds for 24 hours; peritonitis can take days to manifest despite normal bowel sounds

INSTRUMENT & SITE RISK AT A GLANCE

Anterior wall 40% · Cervical canal 36% Suction cannula 51.3% · Hegar 24.4% · Curette 16.2%

ABBREVIATION KEY

TOP — termination of pregnancy PPH — postpartum haemorrhage

ERPC — evacuation of retained products of conception GMC — General Medical Council

RCOG — Royal College of Obstetricians and Gynaecologists IUD — intrauterine device

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — Shakir F, Diab Y. The perforated uterus. TOG 2013;15:256–261. doi:10.1111/tog.12056

Clinically reviewed by NHS obstetricians and gynaecologists

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