Let's talk about uterine perforation as a serious complication of intrauterine manipulation. Clinic, main causes and treatment of uterine perforation

During an artificial abortion, when curettage of the pregnant uterus, perforation of its wall occurred with prolapse of the omentum. What should I do? Conservative treatment can be used for uterine perforations if the perforation is small, there is no internal bleeding, and there are no signs of infection or damage internal organs or their loss through the perforation hole. This is usually observed when perforation of the uterus a probe, an expander and, sometimes, a small curette, and also provided that after perforation all manipulations were immediately stopped (Fig. 79). A favorable circumstance is complete emptying uterus before perforation. Retention in the uterus of parts ovum leads to bleeding, interferes with uterine contraction and closure of the perforation.

Rice. 79. Perforation of the uterus in the fundus during curettage (a); perforation back wall uterus with a sharp curette (b).

If a perforation of the uterus is suspected, the operation is immediately suspended, the instruments are carefully removed and the patient is placed in the Fowler position. She is prescribed complete rest, cold on the lower abdomen, penicillin and uterine contractions (pituitrin, ergotine, etc.). The patient is strictly monitored so as not to notice the beginning of bleeding or symptoms of peritonitis that require surgical intervention. In the absence of increased heart rate, increased temperature and negative Shchetkin-Blumberg sign in the hypogastric region, you can continue conservative treatment.

The prognosis in these cases is usually favorable. The resulting wound of the uterus is small in size, bleeding is insignificant. If a small accumulation of blood in the form of a uterine blood tumor forms in the Dutlas pouch, the latter quickly resolves. Strong contractions of the uterine muscles help close the perforation, which prevents infection from entering the abdominal cavity from the uterus. If the omentum is pinched in the perforation channel, this is accompanied by the formation of adhesions.

If there is a perforation of the uterus with a Hegar dilator during the expansion of the cervical canal (Fig. 80, a), especially not penetrating, one can limit oneself to conservative measures. TO surgical intervention must be resorted to in exceptional cases, if the branches are damaged as a result of a cervical injury uterine artery and bleeding or hematoma formation is observed (Fig. 80, b). It is more difficult to resolve the issue if curettage was started when the cervix was incompletely perforated. In such cases, bleeding from the uterus in the presence of parts of the fetal egg in the latter may force a decision to continue curettage, which in such cases should be done very carefully. When inserting a curette, given the location of the perforation hole in the neck, this should be avoided dangerous place.

Rice. 80. Perforation of the cervix with a Hegar dilator (a); perforation of the cervix. Hematoma of the broad ligament (b).

If the operator did not catch the moment at which the uterus was perforated and continued curettage or inserted an abortion forceps, forceps or a large curette into the uterus (Fig. 81), then the instrument could enter the abdominal cavity through the perforation, causing damage to the internal organs. In this case conservative method treatment is extremely risky and should not be used. A large perforation is usually accompanied by bleeding; upon healing, a wide scar is formed, which during subsequent pregnancy carries the threat of uterine rupture. Infection in the abdominal cavity or damage to internal organs (intestines) can cause general peritonitis, the development of which is prevented by an operation performed following perforation of the uterus. Therefore, in such cases, and especially when prolapse through a perforation of the intestine or omentum, immediate transection is indicated.

Rice. 81. Perforation of the uterus with an abortion tool, which captures a loop of intestine.

Patients with uterine perforations caused by someone else's hand must also be operated on. This will help save from severe complications and even death of more than one patient and fully justifies our intervention, even if sometimes there is only a small perforation hole without other complications.

Recognition of uncomplicated uterine perforations in some cases presents significant difficulties.

Perforation of the uterus is usually indicated by the fact that the instrument suddenly “falls through”, goes into the uterine cavity to a greater depth than its length, and does not meet resistance from the walls of the uterus. IN in rare cases deep, penetration of the instrument is observed without perforation with a sudden atonic state of the uterus and a sharp increase in its cavity, which is recognized by palpation of the uterus.

I. L. Braude (1959) points out that a suspicion of perforation of the uterus arises if, during curettage, the curette stops removing parts of the fetal egg, and bleeding continues or intensifies. This situation at the beginning of the operation, when the fertilized egg is still in the uterus, is very suspicious. If the bleeding continues at the end of the operation, and parts of the fetal egg are not removed with the curette, the bleeding continues, then either the emptying of the uterus is not completed, or the curette moves into abdominal cavity or in the pelvic tissue, which is accompanied acute pain, symptoms of shock and confirms the diagnosis of perforation.

The symptom given by I.B. Braude should be taken into account with caution, since at the beginning of curettage, an inexperienced doctor may not immediately find the place of attachment of the fertilized egg, and the bleeding that begins will cause him unreasonable anxiety.

At the end of the operation, bleeding may depend on the atonic state of the uterus when it is completely emptied of the fertilized egg. Only in combination with other signs do the symptoms described by I. L. Braude help make a diagnosis of uterine perforation.

If there is any doubt about perforation of the uterus, if the possibility of infection is excluded, test probing is used, which, however, if the perforation is small, may not detect it. The possibility of new perforation of the uterus cannot be ruled out if there is a persistent desire to find a suspected perforation. Test probing is contraindicated in case of infection of the uterine cavity.

Based on the above, the value of trial probing is not great. When perforated with a probe, dilator or small curette, the hole is small, complications are usually absent, and since most of these patients are treated conservatively, trial probing can only worsen the situation. With complicated perforations, the diagnosis most often does not cause any particular difficulties, and since in these cases transection is used, preliminary probing is pointless.

I. L. Braude (1959) in cases where there is a suspicion of uterine perforation, and conservative treatment is dangerous, recommends performing a posterior colpotomy instead of a trial transection, which allows resolving the issue of perforation and suturing the perforation.

Undoubtedly, posterior colpotomy has advantages over transection, especially in infected cases. However, in obstetrics and gynecology practice, abdominal dissection is more often used, the technique of which is more familiar to the general public. In addition, with transsection, examination of the uterus and other abdominal organs and interventions on them in case of damage are easier and better than with colpotomy.

Rice. 82. Multiple perforations of the uterus during curettage.

For complicated uterine perforations(Fig. 82), which are accompanied by prolapse of internal organs (omentum, intestines (Fig. 83), etc.), heavy bleeding or shock, the diagnosis is not difficult. With heavy bleeding, it can be detected free liquid in the abdominal cavity or a rapidly expanding hematoma in the broad ligament.

Rice. 83. Perforation of the uterus with separation small intestine from the mesentery.

Symptoms of shock - pallor skin, cold sweat, drop in pulse and blood pressure - appear after perforation and feeling severe pain usually associated with irritation pelvic peritoneum with damage caused by instruments, or with tension in the intestinal mesentery when removing a loop of intestine. The phenomena of shock, if manipulation of instruments in the abdominal cavity stops, decreases and, being mild, may go unnoticed or be explained by painful irritations during abortion and blood loss.

Uncomplicated uterine perforation may pass unnoticed for the patient - this cannot be ignored. Completed perforation may be indicated by the removal of pieces of adipose tissue from the uterus, indicating damage to the omentum, mesentery, or fatty appendages of the colon.

It can be difficult to diagnose perforation of the uterus if inflammation of the peritoneum has already developed and the anamnesis does not provide clear indications of the possibility of perforation. At in serious condition patient and peritonitis caused by perforation of the uterus or another process, transsection is indicated for the purpose of treatment, in which the diagnosis is clarified.

In cases where inflammation does not involve the entire peritoneum, correct diagnosis plays very important role. With a normal inflammatory process within the pelvis, conservative treatment is the most reasonable, and surgery is resorted to only when exudate forms, and even then not in all patients.

For inflammation caused by uterine perforation, the best results are obtained surgical treatment.

At differential diagnosis Anamnesis helps. If there was no inflammatory process before curettage of the uterus, peritoneal phenomena appeared immediately after curettage and developed rapidly, then this indicates perforation. However, such a development of the disease is not always observed with perforation; the phenomena may increase slowly, or rapid development occurs after curettage, during which a breakthrough into the abdominal cavity of the pyosalpinx occurred.

If there is uncertainty in the diagnosis (inflammation or perforation of the uterus, causing pernoneal phenomena), when the patient’s condition does not cause serious concern and the perforation is doubtful, one has to take a wait-and-see approach. In this case, conservative treatment is used (rest, cold on the abdomen, antibiotics, etc.) and strict observation under conditions that allow surgery when peritoneal phenomena increase.

We had to repeatedly encounter a similar situation during abortions caused by insertion into the uterus various liquids(soap solution, etc.). Such patients were admitted with the onset or incomplete abortion and peritoneal phenomena, which with conservative treatment decreased or disappeared within 6-12 hours.

Perforation, uterus during abortion in a hospital setting occurs during intrauterine use of instruments. Perforation of the uterus can be done with any instrument, even just a finger. X. I. Barsky (1932), A. S. Madzhuginsky (1933), E. A. Chernukha (1964), and others indicate that most often damage to the uterus during abortion is caused by a curette, more rarely by abortion forceps and smallest number perforations are made by expanders. Particularly dangerous is the use of dilators with sharp ends, small curettes and forceps, which under no circumstances should be used to remove parts of the fertilized egg from the uterus. An abortion forceps should only be used to remove parts of the fertilized egg that has already been crushed and separated from the uterine wall. When pregnancy is up to 10 weeks, it is usually unnecessary to insert an abortion tool into the uterine cavity; it should be used to remove parts of the fertilized egg that have been brought down by a curette into the cervical canal. Of the various modifications of abortion forceps, the best are the forceps of R.V. Kiparsky and Zenger with round blunt ends.

Small-sized curettes should be used only after most of the fetal egg has been removed, the uterus has contracted and its walls have become dense, and before that, large blunt-ended curettes are used, with which the fertilized egg is destroyed and separated from the walls of the uterus.

Perforation of the uterus is more possible during pregnancy at 12 weeks or more, when the wall of the uterus is greatly stretched and thinned, and its cavity is large and difficult to navigate during curettage. Changes in the uterine wall that occur with infantilism, developmental defects, inflammatory diseases and neoplasms lead to excessive fragility, flabbiness and thinning. Under these conditions, perforation of the uterus occurs especially easily. The introduction of a forceps with a sharp end into the uterine cavity, the use of a small sharp curette at the beginning of curettage when the uterus is not contracting, as well as ignorance of the position of the uterus in a given pregnant woman and incorrect surgical technique as a result of inexperience or haste (hasty) of the operator - these are the reasons contributing to the occurrence of perforation uterus.

Emergency care in obstetrics and gynecology, L.S. Persianinov, N.N. Rasstrigin, 1983

Description:

Perforation of the uterus - the most common complication both during diagnostic and operational hysteroscopy. Perforation may occur during expansion cervical canal or performing any surgical procedures in the uterine cavity.

Cause of uterine perforation:

The reasons may be:
1. Pronounced retroversion of the uterus.
2. Insertion of the hysteroscope without good visibility.
3. Common endometrial carcinoma.
4. Elderly age sick, conditioning age-related changes tissues (cervical atrophy, loss of tissue elasticity).

The endoscopist should immediately identify the uterine perforation that has occurred.

Symptoms of uterine perforation:

Signs of uterine perforation during hysteroscopy:
1. The dilator enters to a depth greater than the expected length of the uterine cavity.
2. There is no outflow of the injected fluid or it is not possible to maintain pressure in the uterine cavity.
3. Loops of intestine or pelvic peritoneum may be visible.
4. If the hysteroscope is in the parametrium (non-penetrating perforation of the leaves of the wide uterine ligaments), the endoscopist sees a very interesting picture: thin threads, similar to a delicate veil.
5. With non-penetrating perforation of the uterine wall, the visible picture is difficult to interpret correctly.

If there is perforation of the uterus (or suspected perforation), the operation is stopped immediately. The tactics for managing a patient with uterine perforation depends on the size of the perforation hole, its location, the mechanism of perforation, and the likelihood of damage to the abdominal organs.

Treatment of uterine perforation:

Conservative treatment of uterine perforation is indicated when the size of the perforation hole is small and there is confidence in the absence of damage to the abdominal organs, the absence of signs of intra-abdominal or hematomas in the parametrium.

Prescribe cold to the lower abdomen, uterine contractions, and antibiotics. Carry out dynamic observation.

Perforation of the lateral wall of the uterus is rare, but can result in a mass in the broad ligament. If the hematoma enlarges, it is indicated.

Serious perforations occur when working with the resector, resectoscope and laser. Endoscopic scissors inserted through the operating channel of a hysteroscope can rarely damage neighboring organs; more often this happens when working with a resectoscope or laser. The risk of uterine perforation is greatest when dissecting intrauterine synechiae III degree and more. With this pathology, it is difficult to recognize anatomical landmarks, so it is recommended to perform control laparoscopy. The incidence of uterine perforation during dissection of intrauterine synechiae, even with laparoscopic control, is 2-3 per 100 operations.

Perforation during surgical hysteroscopy is easy to recognize, since the intrauterine pressure drops sharply due to the release of fluid into the abdominal cavity, and visibility sharply deteriorates. If at this moment the electrode has not been activated, the operation is stopped immediately and if there are no signs intra-abdominal bleeding conservative treatment is prescribed. If the surgeon is not sure whether the electrode was activated at the time of perforation, and there is a possibility of damage to the abdominal organs, laparoscopy with suturing of the perforation hole and revision of the abdominal organs is indicated, and, if necessary, laparotomy.

Prevention:

Gentle dilatation of the cervix, possible use kelp.
- Insertion of the hysteroscope into the uterine cavity under visual control.
- Correct technical execution of the operation.
- Taking into account the probable thickness of the uterine wall in different parts of it.
- Laparoscopic control during complex operations with the risk of perforation of the uterine wall.

Many intrauterine operations and manipulations are performed by the doctor almost blindly. In 1% of cases of all interventions, perforation of the uterus can occur - this is a through wound of its wall with a surgical instrument.

Causes of injury

The greatest danger from the point of view of injury to the uterine wall are the abortion forceps and curettes, which have a sharp edge. At the same time, neighboring organs may be injured. The Hegar dilator is rounded at the end and has a large thickness, so it is much more difficult for them to perforate the organ. In 0.3% of cases, perforation of the uterus is possible when an IUD is inserted.

The leading cause of injury is technically considered incorrect execution intrauterine interventions. Perforation of the organ wall can occur during the following operations:

medical abortion;
separate therapeutic and diagnostic curettage;
hysteroscopy;
introduction intrauterine device.

It is believed that to pierce the wall healthy organ almost impossible: it is quite elastic and durable. And when various diseases The tissue structure is loose and fragile, so damage becomes possible.

The risk of uterine perforation increases in the following cases:

acute or chronic inflammation -;
myomatous nodes of various locations;
scar after artificial birth or surgical interventions;
frequent intrauterine interventions, including abortions and diagnostic ones;
recent surgery, less than six months have passed since;
abortion after 12 weeks of gestation;
uterine hypoplasia;
age characteristics during;
posterior deviation of the organ (retroversion);
endometrial cancer.

Injuries with a uterine probe are rare and do not lead to heavy bleeding. The Hegar dilator is dangerous only in case of rough manipulation and with a pronounced bend of the uterine body anteriorly or posteriorly. If a wall is perforated with its help, a large hole with heavy bleeding. But the greatest danger is posed by the curette and abortion forceps, which account for up to 80% of traumatic perforations.

The curette (above) and the abortion forceps are the most dangerous surgical instruments from the point of view of injury to the uterine wall.

Spiral perforation

If damage to the IUD has led to its release into the abdominal cavity, it must be removed as quickly as possible, especially for copper-containing IUDs. Copper ions lead to inflammatory reaction. The manipulation is performed laparoscopically. But if necessary, it is expanded to laparotomy. The patient is informed before the operation that if large quantity adhesions in the abdominal cavity, injuries to other organs, the course of the operation will be changed.

Injury to other pelvic organs - intestines, Bladder– requires the work of a surgeon, not a gynecologist.

For multiple major damage uterus and if suturing the defects does not stop the bleeding, resort to extreme method- organ amputation. Bleeding due to injury to the vessels of the uterus is massive and often leads to disseminated intravascular coagulation syndrome. Therefore, in order to save the patient’s life, doctors have to take extreme measures.

Treatment acute blood loss depends on the severity of the condition. Held antishock therapy, as well as restoration of circulating blood volume. For this purpose, colloidal and crystalloid solutions are used, which compensate for the deficiency with liquid and also restore the ionic composition. Depending on the clinical situation plasma is used and blood transfusions are performed. If bleeding has just occurred, then reinfusion of your own blood collected from the abdominal cavity is possible.

Antibiotics are required in all cases of perforation. Drugs are selected wide range actions from the group of cephalosporins (Cefotaxime, Ceftriaxone), Gentamicin, for the prevention anaerobic infection Metronidazole.

Rehabilitation and prevention

The consequences of uterine trauma depend on the extent of damage. Large perforations heal with the formation of a scar. After such an injury, a woman is registered at the antenatal clinic.

Pregnancy following uterine perforation may be complicated by:

weakness of labor;
untimely discharge of amniotic fluid;
threat of uterine rupture along the scar;
bleeding in the postpartum period.

Pregnancy in such patients should be carefully planned. A preliminary examination of the condition of the scar is necessary. It is recommended to become pregnant no earlier than 2 years after the injury.

The consequences of perforation vary in severity. Intervention in the abdominal cavity often ends in the formation of adhesions. Injury can be avoided with proper prevention.

Women from risk groups deserve special attention:

With acute or chronic endometritis.
With a scar on the uterus after surgical interventions (,).
Frequent intrauterine manipulations (abortions, diagnostic curettages).
After recent (less than 6 months) surgery.

To avoid being at risk, you should: simple recommendations. Any infection should be treated using full course antibiotics. This must be done in a timely manner to prevent transition acute form into chronic.

To reduce the amount of intervention to surgical removal myomatous node can be used drug therapy(medical castration). Under the influence of drugs that reduce estrogen levels, the nodes become smaller; large incisions in the uterus are not required.

Abortion should be avoided and chosen carefully. Coitus interruptus is not one of them. Optimal method in each case you can discuss with your doctor.

Timely treatment of non-inflammatory diseases of the genital organs will reduce the likelihood frequent curettages, and therefore the risk of perforation with one of them.

Content

Perforation of the uterus is dangerous condition, provoked by actions medical worker. Pathology requires immediate treatment, as it is life-threatening. Modern diagnostic techniques allow timely detection of uterine perforation and prevent complications.

Reasons and forms

Uterine perforation occurs during therapeutic and diagnostic manipulations in the pelvic area. The main causes of pathology are:

abortion (especially later pregnancy);
hysteroscopy;
biopsy;
curettage to clarify the diagnosis;
installation of an intrauterine contraceptive device.

Predisposing risk factors are:

spicy or chronic endometritis;
scarring of muscle tissue as a result of surgery;
interventions carried out shortly before the next manipulation;
tumor processes;
uterine hypoplasia;
bend;
changes associated with menopause;

There are complete and incomplete damage to the walls of the uterus:

incomplete perforation includes defects in which the outer layer reproductive organ(damage occurs internally);
complete perforation is a lesion that extends through the entire thickness of the organ.

An important task for physicians is to differentiate pathological conditions. Full perforation represents serious threat for the health and life of a woman. Damage can be uncomplicated or complicated. In the latter case, not only the wall of the uterus is injured, but also neighboring organs.

The most common type of complete perforation occurs during diagnostic curettage and surgical abortion. These procedures use sharp-edged instruments that easily cut the mucous membrane.

Symptoms and diagnosis

Perforation of the uterus, which is characterized by clear symptoms, cannot go unnoticed. It is impossible to live with this pathology and not suspect your condition. Often, the patient is unconscious at the moment when damage to the mucous layer of the uterus occurs, so doctors cannot always quickly determine the development pathological process. The main sign of perforation is sudden bleeding. Doctors may also discover that the patient has decreased arterial pressure, and the heart rate increased. If we talk about the symptoms that worry a woman, then uterine perforation is indicated by pain in the abdomen and back, dizziness and weakness.

All gynecologists know what uterine perforation is. Therefore, the doctor can easily suspect damage to the muscle layer already at the time of surgery. The main symptom is tool failure. In most cases, the intervention is carried out blindly, so unexpected deepening of the curette or other device suggests perforation.

It is not difficult to diagnose the pathology if a loop of intestine, omentum or ovary is removed during surgery. In this case, doctors have no doubts. Hysteroscopy requires creating pressure in the uterine cavity. If damage to the walls occurs, it is reduced. In this case, the hysteroscope is lowered to a greater depth than was intended.

If perforation occurs during installation of the intrauterine device or during its operation, the doctor detects the absence of antennae in the cervix. When trying to remove the contraceptive, difficulty arises. When diagnosing, the patient’s complaints must be taken into account if she is conscious.

Suspicion of uterine perforation forces the doctor to conduct a more detailed diagnosis. For this purpose it is carried out ultrasound scanning. During the examination, the presence of free fluid in the abdominal cavity may be detected, which indicates internal bleeding. A more accurate picture of damage to neighboring organs and the condition of the uterine walls will be shown. diagnostic laparoscopy, which, if necessary, immediately goes into treatment.

Treatment

Perforation of the uterus in most cases is treated surgically. Only incomplete damage to the walls of the reproductive organ allows conservative therapy. Treatment involves the use antibacterial drugs, preventing wound infection, and hemostatic agents. In some cases, antispasmodics, anti-inflammatory and contractive medications are prescribed. During conservative therapy, the patient's condition is carefully monitored. Lack of improvements obliges to apply surgical techniques restoring the integrity of damaged uterine walls.

Complete perforation involves emergency surgery. Depending on capabilities medical institution, surgical intervention carried out laparoscopically or laparotomically. The timing of the operation is determined by the severity of the patient’s condition. Suturing the damage takes no more than 30-60 minutes. If perforated abdominal organs are detected, treatment may be delayed.

Amputation of the uterus is carried out with multiple injuries and massive bleeding, life-threatening patients.

After surgery, the woman is under the supervision of specialists for 1-2 weeks. During this period, therapy is supplemented medications.

Complications

Perforation of the uterus itself is a complication of therapeutic or diagnostic procedure. Damage to the walls of the reproductive chamber can be aggravated by the following circumstances:

perforation of organs located nearby (when the integrity of the intestines, bladder, ovary, fallopian tubes is disrupted);
peritonitis (the inner lining of the peritoneum becomes inflamed due to the penetration of pathogenic flora);
hematoma (a blood clot forms in organs located near the uterus);
lethal outcome (occurs due to large blood loss and late diagnosis perforation of the uterus).

To avoid damage to the thickness of the uterus, it is necessary to carefully prepare for any type of intervention. Before the procedure, it is important to exclude inflammatory process. You should first do an ultrasound and gynecological examination to assess the size and position of the organ being examined. Perforation can be prevented if any intervention is carried out under the control of an ultrasound scanner.

At incorrect position reproductive organ before intrauterine intervention Forceps are applied to the neck to eliminate the refraction angle.

Forecast

Perforation of the reproductive organ, detected in a timely manner, does not pose a threat to the patient’s life. However, there may be problems with reproductive function in the future. Complete perforation requires suturing, which leads to scarring of the injury site. Throughout pregnancy, a woman remains at risk of rupture of this zone, since it muscle is replaced by a connecting one. For women carrying a child after uterine perforation, special control and frequent ultrasound monitoring.

– perforation of the organ wall during intrauterine manipulation. Manifested by intense pain in lower parts abdomen and signs of intra-abdominal bleeding: bloody vaginal discharge, weakness, dizziness, tachycardia. May be combined with trauma to the abdominal organs. Uterine perforation is detected based on history, clinical findings, transvaginal ultrasound, hysteroscopy and laparoscopy. Depending on the severity of the defect, either a conservative expectant approach is used, or surgical intervention is performed (suturing the perforation, amputation/extirpation of the uterus).

General information

Perforation of the uterus - through damage uterine wall surgical instruments at intrauterine procedures. In gynecology, it refers to iatrogenic pathology caused by careless actions medical personnel. Perforation of the uterus occurs in 1% of gynecological patients who have undergone intracavitary manipulations (abortion, RDV, probing of the uterine cavity, hysteroscopy, etc.). There are complete (through) perforation of the uterus with damage to the entire thickness of the wall and incomplete (without perforation serous membrane). In this case, complete perforation can be uncomplicated (with intact internal organs) and complicated (with trauma to the uterine appendages, bladder, intestines, omentum, etc.). Perforation of the uterus is a serious complication, as it can lead to life-threatening bleeding, peritonitis, loss of reproductive function.

Causes of uterine perforation

Regardless of the immediate causes, perforation of the uterus always results from a violation of the technique. gynecological manipulations: abortion, removal of the fertilized egg during a frozen pregnancy, diagnostic curettage, diagnostic hysteroscopy, hysteroresectoscopy, laser reconstruction of the uterine cavity, separation of intrauterine synechiae, installation of an IUD.

Statistically, perforation of the uterine wall occurs more often during artificial abortion. In this case, perforation can occur at any stage of the minor surgery: during probing of the uterine cavity (2-5%), expansion of the cervical canal (5-15%), removal of the fertilized egg with an abortion forcemer or curette (80-90%). If damage to the uterus by a probe usually does not lead to excessive internal bleeding and injury pelvic organs, then gross dilatation of the cervical canal with Hegar dilators can lead to tears internal pharynx, perforation of the isthmus and lower segment of the uterine body. The most dangerous is perforation of the uterus with a curette and abortion forceps - in this case, the perforation hole may be located in the area of the fundus or walls of the uterus, have big sizes. Such perforation is often accompanied by heavy blood loss and injuries to the abdominal organs.

Predisposing factors that increase the likelihood of perforation should be considered severe retroflexion of the uterus, uterine hypoplasia, acute and chronic endometritis, endometrial cancer, the presence postoperative scar on the wall of the organ, age-related involution of the uterus. In addition, the risk of perforation increases significantly in cases where induced abortion performed in an out-of-hospital setting, over 12 weeks of pregnancy, the actions of the operating gynecologist are rude and hasty, instruments are inserted into the uterine cavity without sufficient visual, ultrasound or endoscopic control.

Symptoms of uterine perforation

Signs of uterine perforation depend on its nature (complete/incomplete, complicated/uncomplicated) and location. If there is incomplete perforation or the perforation is covered by some organ (for example, the omentum), symptoms may be absent or mild. You can think about uterine perforation if, after undergoing intrauterine manipulation, the patient complains of sharp pains in the lower abdomen, abundant bloody issues from the vagina, dizziness and weakness. With significant internal bleeding, pale skin, tachycardia, drop in blood pressure, and tension in the abdominal wall are noted.

Delayed diagnosis of uterine perforation can lead to serious and life-threatening complications and consequences. These include intestinal injuries or bladder injuries, massive hematomas, bleeding, peritonitis, sepsis. Damage to the internal uterine os can contribute to the formation of isthmic-cervical insufficiency and miscarriage during a subsequent pregnancy. Perforation of the uterus may have serious consequences for reproductive function and cause the development of infertility due to the formation of intrauterine adhesions (Asherman syndrome) or the need to remove the uterus.

Diagnosis of uterine perforation

Directly during intrauterine intervention, perforation can be suspected by the feeling of the instrument “falling through” outside the uterine cavity. In complicated cases, perforation is indicated by the removal of a loop of intestine, omentum, or ovary from the uterus. A sign of uterine perforation when installing an intrauterine contraceptive is the absence of threads in the area of the uterine pharynx, visible during vaginal examination, and if they are present, the impossibility of removing the IUD “by the mustache” (feeling of resistance, sharp pain).

If the manipulation is performed under hysteroscopic control, then the endoscopist can focus on following signs: it is not possible to maintain stable pressure in the uterine cavity, there is no outflow of injected fluid, the peritoneum, intestinal loops or other internal organs are visible on the monitor. If the operating surgeon has reason to suspect that perforation of the uterus has occurred, he should immediately suspend all actions and try to palpate the end of the instrument through abdominal wall to confirm its location.

In cases where uterine perforation is not recognized on operating table, V timely diagnosis complications are helped by careful observation of the patient in the first hours after the manipulation, analysis of complaints and obstetric and gynecological history. Additional information is obtained using transvaginal ultrasound, which allows you to detect free fluid in the pelvis. In most cases of uterine perforation, diagnostic laparoscopy is performed to exclude damage to the abdominal organs.

Treatment of uterine perforation

Further tactics for uterine perforation are determined by the timeliness of recognition of the defect, its size, location, mechanism of injury, and the involvement of internal organs. If the perforation is incomplete, the hole is small, and there is absolute confidence in the absence of damage to the abdominal cavity, parametrial hematoma and intra-abdominal bleeding, conservative observational tactics can be taken. In this case it is assigned bed rest, cold on the stomach, uterotonic drugs and antibiotics are used. Dynamic ultrasonic testing is carried out.

In other situations (in the presence of peritoneal symptoms and increasing signs internal bleeding) laparoscopy or laparotomy, a thorough revision of OMT and OBP are indicated. If a small defect is detected in the wall of the uterus, they limit themselves to suturing the wound. If multiple or large ruptures of the uterine wall are detected, the issue is resolved in favor of supravaginal amputation (removal of the uterus without the cervix) or even hysterectomy ( complete removal uterus). In case of perforation of the uterus, complicated by injury to adjacent organs, the scope of the surgical procedure is supplemented by appropriate interventions. To replenish blood loss, it is carried out infusion therapy, transfusion of blood components, for prevention infectious complications – antibacterial therapy.

Forecast and prevention of uterine perforation

The prognosis for a woman’s life with timely diagnosis and elimination of uterine perforation is favorable, but the consequences for reproductive function can be very serious. In order to prevent uterine perforation, it is necessary to follow the technique and phasing of various intrauterine interventions, insert instruments into the uterine cavity carefully, if possible under visual control. The patient herself can minimize the risk of uterine perforation by refusing abortion and regularly visiting a gynecologist. Women who have suffered a perforation of the uterine wall are subject to registration at the dispensary. Pregnancy management in such patients is associated with many risks, primarily the risk of miscarriage and