Richards et al reviewed uterine perforation associated with an intrauterine procedure. An iatrogenic perforation may range from a minor to life-threatening event. The authors are from the Cleveland Clinic.
Risk factors for perforation:
(1) postpartum procedure
(2) operative hysteroscopy
(3) difficult access to the endometrial cavity (cervical stenosis, severe anteflexion or retroflexion)
(4) menopause
(5) prior myomectomy
(6) inadequate preoperative evaluation
Clinical recognition:
(1) direct visualization of perforation
(2) return of fat or bowel wall in curettage specimen
(3) unexplained excessive bleeding
(4) unexplained hypotension
(5) unexplained hematuria
How a perforation is managed depends on the location, clinical findings, and patient status.
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Location
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Management
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anterior
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proctoscopy and immediate repair; cystoscopy for hematuria
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posterior
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proctoscopy and immediate repair; cystoscopy for hematuria
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lateral
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evaluate for bleeding; profuse bleeding requires laparoscopy or laparotomy
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fundal
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expectantly; abdominal exploration; suturing of defect
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Delayed recognition may be triggered by:
(1) worsening pelvic pain
(2) abdominal distention
(3) fever
(4) hemodynamic instability
(5) vaginal discharge
