Many interventions and operations inside the uterus are performed by a specialist almost blindly. Perforation of the uterus can occur in only one percent of all cases. It is understood as a through wound of the uterine wall with a surgeon's tool.
Causes
Regardless of the direct reasons, uterine perforation (according to ICD-10 code - O71.5) always leads to violations during surgical interventions in the gynecological field: abortion, diagnostic curettage, installation of a spiral, removal of a fetal egg during a dead pregnancy, separation of synechia inside the uterus, diagnostic hysteroscopy, laser reconstruction of the uterine cavity, hysteroresectoscopy.
More often, according to statistics, perforation of the uterine wall appears during the implementation of artificial termination of pregnancy. Perforation in this case can happen at any stage of surgical intervention: during probing of the uterine cavity (from 2 to 5%), removal of the ovum by a curette or abortion (from 80 to 90%), expansion of the cervical canal (from 5 to 15%). If perforation of the uterus during curettage with an ordinary probe most often does not cause severe internal bleeding and damage to the pelvic organs, then due to gross dilatation by Gegar's dilators, the cervical canal can cause tears in the internal pharynx. Perforation in the lower segment and uterine isthmus often also occurs. Perforation of the uterus during abortion and a curette is especially dangerous - in this case, the perforation hole may be in the area of the walls of the uterus or the bottom, and may have large dimensions. Such perforation is often accompanied by severe loss of blood and injuries of the abdominal organs.
Predisposing factors
Predisposing factors that increase the possibility of uterine perforation are severe uterine retroflexion, chronic and acute endometritis, uterine hypoplasia, endometrial cancer, organ involution with age, the presence of a scar on the uterine wall after surgery.
In addition, the likelihood of perforation increases significantly when an artificial abortion is performed outside the hospital, for a period of more than 12 weeks, the gynecologist’s actions are hasty and rough during surgery, the instruments are inserted into the uterine cavity without sufficient endoscopic, ultrasound or visual inspection of the organ.
Perforation of the uterus from the IUD is possible.
Spiral damage to the uterus
The intrauterine device is inserted blindly, the accuracy of the procedure directly depends on the tactile sensations of the doctor and his technique.
The reason for uterine perforation is based on the fact that the organ cavity does not always coincide with the cervical canal along the axis.
Sometimes the uterine wall is very thin in the lower segment, which is a risk factor. Also, an additional risk appears when installing the spiral earlier than six months after giving birth, and immediately after artificial abortion.
After the spiral, uterine perforation is observed immediately after the procedure, and as spontaneous consequences after a certain time after administration. In some cases, this is detected by removing the spiral. In such a situation, the threads will be lost or removal of the spiral will be difficult.
You can also injure the uterus with a spiral at the injection stage, if there were active contractions of the myometrium, that is, an expulsion that expels the agent. In this case, the cervix is perforated, since there is no coincidence of the axis of the cervical canal with the axis of the organ.
Signs
Symptoms of uterine perforation are determined by its features (uncomplicated / complicated, incomplete / complete) and location. If an incomplete perforation has occurred or the hole that has appeared is closed by a certain organ (for example, an omentum), signs may be poorly expressed or even absent. It is possible to suspect uterine perforation during abortion only when, after the manipulation inside the organ, a woman complains of strong discharge of blood from the vagina, sharp pains in the lower abdomen, weakness and dizziness. With severe internal bleeding, tension of the peritoneal wall, pallor of the skin, decreased pressure, tachycardia appear.
Consequences and Complications
Untimely diagnosis of uterine perforation can cause life-threatening and serious consequences and complications. These include intestinal wounds or injuries of the bladder, extensive hematomas, sepsis, peritonitis, and bleeding. Damage to the internal pharynx of the uterus can cause the formation of isthmic-cervical insufficiency, as well as miscarriage during pregnancy in the future. Uterine perforation can have significant consequences for reproductive function and cause infertility due to the formation of adhesions inside the uterus (Asherman syndrome) or the need to remove the organ altogether.
Diagnostics
Immediately during an intervention inside the uterus, the perforation that has occurred can be suspected only by the sensation of a "fall" of the surgical instrument beyond the borders of the uterine cavity. Perforation in complicated cases may indicate extraction from an organ of the ovary, omentum, or intestinal loop. A symptom of perforation when installing a contraceptive inside the uterus is the absence of threads in the uterine throat, visible when examining the vagina, and if there is one, there is no possibility of removing the spiral behind its "mustache" (sharp pain and a sense of resistance).
When performing manipulations under hysteroscopic supervision, the endoscopist can look at the following symptoms: in the uterine cavity, it is not possible to maintain stable pressure; there is no outflow of fluid introduced to the patient; on the monitor, the doctor sees intestinal loops, peritoneum, or other internal organs. If the operating specialist has grounds for assuming that uterine perforation has occurred, he should immediately suspend any manipulations and try to palpate the tip of the instrument through the abdominal wall to make sure that it is localized.
If uterine perforation is not determined on the operating table, then close attention to the woman in the first hours after the intervention helps to see complications with timely diagnosis; analysis of obstetric and gynecological history and patient complaints. Additional information is obtained through transvaginal ultrasound, which allows you to see free fluid in the pelvis. In most cases of uterine perforation, diagnostic laparoscopy is done to exclude disorders of the peritoneal cavity organs.
Treatment of uterine perforation
In the future, the tactics of therapy depends on the timely detection of violations, their location, size, mechanism of injury, monitoring internal organs. With incomplete perforation and a small hole, if there is full confidence that there is no damage to the OBP, there is no bleeding inside the peritoneum and parametric hematoma, a conservative-observational tactic may be chosen. In this case, the woman needs bed rest, cold is placed on her stomach, antibiotics and uterotonic agents are used (Enzaprost-F, Prepidil, Sigentin, Erogometrin). Ultrasonic dynamic control is carried out.
The remaining cases (if there are growing symptoms of internal bleeding or the presence of peritoneal symptoms) require laparotomy or laparoscopy, a thorough study of OBP and OMT. If small abnormalities were detected in the uterine wall, then everything is limited to suturing the wound. When determining large or multiple ruptures of the uterine wall, the problem is solved using supravaginal amputation (the uterus is removed without the cervix) or hysterectomy (the uterus is completely removed).
With uterine perforation complicated by a violation of neighboring organs, surgical interventions are supplemented by the necessary procedures. In order to make up for the loss of blood, an infusion treatment is carried out, its components are transfused. To prevent complications of an infectious nature, antibacterial treatment is performed.
Prevention and prognosis
For the patient’s life, the prognosis for timely diagnosis and elimination of uterine perforation is favorable, but the consequences for reproductive function can be very serious. To prevent organ perforation, it is necessary to observe the phasing and technique of various kinds of intrauterine operations, to introduce instruments into the uterine cavity carefully, best under visual control. Directly, a woman can minimize the likelihood of such a pathology if she refuses abortion and visits a gynecologist regularly. If patients have suffered perforation of the uterine wall, they are put on a dispensary account. In such women, pregnancy is associated with a large number of risks, especially with the risk of rupture of the uterus and miscarriage.
Reviews
The consequences of uterine trauma depend on the amount of damage, their volume. Patients note that large openings heal, but a scar forms. After such an injury, a woman should be registered in the antenatal clinic.
The consequences of perforation can be different. Patients say that when they intervene in the abdomen, commissures often form. Injury can be avoided with proper prevention.
Also, women say that they have to seriously plan their pregnancy. A preliminary scar study is required. It is best to become pregnant at least two years after perforation. The main thing that is noted in the reviews is the need for careful attention to the state of health and the appeal to trusted doctors.