Many interventions and operations inside the uterus are performed almost blindly by a specialist. 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 the surgeon's instrument.
Reasons
Regardless of the direct causes, perforation of the uterus (according to the ICD-10 code - O71.5) is always caused by violations during surgical interventions in the gynecological field: abortion, diagnostic curettage, installation of a spiral, removal of a fetal egg during a missed pregnancy, separation of synechiae inside the uterus, diagnostic hysteroscopy, laser reconstruction of the uterine cavity, hysteroresectoscopy.
More often, according to statistics, perforation of the uterine wall appears during artificial termination of pregnancy. Perforation in this case can occur at any stage of surgical intervention: during probing of the uterine cavity (from 2 to5%), removal of the fetal egg with a curette or abortion collet (from 80 to 90%), expansion of the cervical canal (from 5 to 15%). If perforation of the uterus during curettage with a conventional probe most often does not cause severe internal bleeding and damage to the pelvic organs, then due to gross dilation of the cervical canal by Hegar dilators, it can cause tears of the internal pharynx. Also often there is a perforation in the lower segment and isthmus of the uterus. Particularly dangerous is the perforation of the uterus during an abortion with an abortion collet and a curette - in this case, the perforation hole can be located in the area of the walls of the uterus or the bottom, and be large. Such perforation is often accompanied by severe blood loss and abdominal trauma.
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 induced abortion is performed outside the hospital, for a period of more than 12 weeks, the gynecologist's actions during the operation are hasty and rough, instruments are inserted into the uterine cavity without sufficient endoscopic, ultrasound or visual control body.
Possible uterine perforation from IUD.
Uterine coil injury
The intrauterine device is inserted blindly, the accuracy of the procedure is directlydepends on the tactile sensations of the doctor and his technique.
The reason for perforation of the uterus 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 a spiral earlier than six months after childbirth, and immediately after an induced abortion.
After the spiral, perforation of the uterus is observed both immediately after the procedure, and as spontaneous consequences after a certain time after the introduction. In some cases, this is detected when extracting the spiral. In such a situation, the threads will be lost or the removal of the spiral will be difficult.
It is possible to injure the uterus with a helix at the injection stage, if there were active contractions of the myometrium, that is, expulsion, which expels the remedy. 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
Uterine perforation symptoms 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), the signs may be weakly expressed or absent altogether. It is possible to suspect perforation of the uterus during an abortion only when, after undergoing manipulation inside the organ, a woman complains of strong discharge of blood from the vagina, sharp pains in the lower abdomen, weakness and dizziness. For severe internal bleedingthere is a tension of the wall of the peritoneum, pallor of the skin, a decrease in pressure, tachycardia.
Consequences and complications
Untimely diagnosis of uterine perforation can cause life-threatening and serious consequences and complications. These include intestinal or bladder injuries, extensive hematomas, sepsis, peritonitis, bleeding. Damage to the internal os of the uterus can cause isthmic-cervical insufficiency, as well as miscarriage during pregnancy in the future. Uterine perforation can have significant reproductive consequences and cause infertility due to the formation of adhesions inside the uterus (Asherman's syndrome) or the need to remove the organ altogether.
Diagnosis
Directly in the process of intervention inside the uterus, it is possible to suspect a perforation that has occurred only by feeling the surgical instrument “fall through” beyond the boundaries of the uterine cavity. In complicated cases, perforation may be indicated by extraction from the 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 area of the uterine os, which is visible when examining the vagina, if they are present, the inability to extract the spiral by its “whiskers” (sharp pain and a feeling 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 supportstable pressure; there is no outflow of fluid administered to the patient; on the monitor, the doctor sees intestinal loops, peritoneum or other internal organs. If the operating specialist has reason to assume 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 in the area of its localization.
If uterine perforation is not detected 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 the obstetric and gynecological history and complaints of the patient. 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 violations of the organs of the peritoneal cavity.
Uterine perforation treatment
In the future, the tactics of therapy depends on the timely detection of violations, their location, size, mechanism of injury, monitoring of internal organs. In case of incomplete perforation and a small hole, if there is complete confidence that there is no damage to the OBP, there is no intraperitoneal bleeding and parametric hematoma, conservative observational tactics can be chosen. In this case, a woman needs bed rest, cold is placed on her stomach, antibiotics and uterotonic drugs are used (Enzaprost-F, Prepidil, Sigentin,"Erogometrin"). Ultrasonic dynamic testing in progress.
Other cases (if there are increasing symptoms of internal bleeding or the presence of peritoneal symptoms) require laparotomy or laparoscopy, a thorough study of OBP and OMT. If small violations 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 with the help of supravaginal amputation (the uterus is removed without a neck) or hysterectomy (the uterus is removed completely).
In case of uterine perforation, complicated by violation of neighboring organs, surgical interventions are supplemented with the necessary procedures. To make up for the loss of blood, infusion treatment is carried out, its components are transfused. To prevent complications of an infectious nature, antibacterial treatment is carried out.
Prevention and prognosis
For the life of the patient, the prognosis for timely diagnosis and elimination of uterine perforation is favorable, but the consequences for reproductive function can be very serious. To prevent perforation of the organ, it is necessary to observe the stages and technique of carrying out various kinds of intrauterine operations, to introduce instruments into the uterine cavity carefully, best of all under visual control. Directly, a woman can minimize the likelihood of such a pathology if she refuses abortions and visits the gynecologist regularly. If the patients suffered a perforation of the uterine wall, they are put on a dispensary record. SuchFor women, pregnancy carries many risks, especially uterine rupture and miscarriage.
Reviews
Consequences of uterine trauma depend on the amount of damage, their volume. Patients note that large holes 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 adhesions are often formed during intervention in the abdomen. Injury can be avoided with proper prevention.
Also, women note that they have to seriously plan pregnancy. A preliminary study of the scar is required. It is best to get pregnant at least two years after the perforation. The main thing that is noted in the reviews is the need for an attentive attitude to the state of he alth and access to trusted doctors.
