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.





proctoscopy and immediate repair; cystoscopy for hematuria


proctoscopy and immediate repair; cystoscopy for hematuria


evaluate for bleeding; profuse bleeding requires laparoscopy or laparotomy


expectantly; abdominal exploration; suturing of defect


Delayed recognition may be triggered by:

(1) worsening pelvic pain

(2) abdominal distention

(3) fever

(4) hemodynamic instability

(5) vaginal discharge

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