Uterine perforation after hysteroscopic myomectomy

45 year-old female who underwent surgical hysteroscopic submucosal myomectomy, with no immediate complications. The patient referred intense abdominal pain of sudden onset 7 hours after surgery. Normal blood test and transvaginal ultrasound, only showing postsurgical changes and a small amount of pelvic fluid. A CT scan is performed showing a large uterine discontinuity with surrounding pelvic hemoperitoneum, free abdominal fluid and pneumoperitoneum. Given these findings, emergency laparotomy is performed, showing large hemoperitoneum and perforation of both the uterine fundus and the adjacent bowel.

Uterine perforation is a potential complication of all intrauterine procedures and may be associated with injury to surrounding blood vessels or viscera (bladder, bowel). In addition, uterine perforation and associated complications can result in hemorrhage or sepsis. The risk of uterine perforation is increased by factors that make access to the endometrial cavity difficult or alter the strength of the myometrial wall. Hysteroscopy is complicated by confirmed uterine perforation in approximately 1 percent of operative procedures. Uterine perforation is generally recognized during the procedure. However, a patient with the following signs or symptoms after an intrauterine procedure should be evaluated for uterine perforation: severe or persistent pelvic or abdominal pain, abdominal distension, heavy or persistent vaginal bleeding, hypotension, hematuria, fever. Bowel may be perforated or become incarcerated in the uterine defect. Such injuries should be suspected if a patient has abdominal distension or continues to have abdominal pain, especially in the presence of tachycardia. Uterine perforation cannot be confirmed or excluded with any imaging study and thus imaging is not a routine part of the evaluation. In women with signs of hypovolemia without apparent bleeding, a pelvic ultrasound can be used to assess for a broad ligament or retroperitoneal hematoma. If there is any concern for ureteral or bladder injury, the integrity of these structures can be easily assessed by the intravenous administration of one of several dyes or by direct visualization. In addition, a catheter or cystoscope can be introduced into the bladder to look for the perforation or fresh blood from an intravesical hemorrhage. If bowel injury is suspected, abdominal exploration is warranted for diagnosis and potential repair. Evaluation of the bowel should be performed by a surgeon experienced in detection of bowel injury.

Uterine perforation after hysteroscopic procedures is very uncommon. Imaging studies are not a routine part of the evaluation of uterine perforation but it might be helpful in some cases.

- Barbara S Levy, MD. Uterine perforation during gynecologic procedures. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on February, 2019.)