Managing uterine perforation

Last reviewed: September 28, 2022

Recommendation:

• Any woman with suspected uterine perforation, even if asymptomatic, should be informed of the complication and her clinical status should be observed.
  • • If stable, women should be told warning signs for when to seek emergency care, if needed, and have a plan for follow-up before discharge from a health center.
    • If unstable or worsening clinical status is noted, transfer to tertiary-level facility for further management.
• Any woman with a known uterine perforation with evidence of bowel injury should be transferred to tertiary-level facility for further management.

Strength of recommendation: Strong

Quality of evidence: Low

Epidemiology

Uterine perforation at the time of vacuum aspiration is a rare but potentially serious complication, estimated to occur in between 0.1-3 per 1,000 induced abortion procedures (Kerns & Steinauer, 2013; Pridmore & Chambers, 1999). This frequency increases with advancing gestational age and when performed by less experienced providers (ACOG, 2019).

Factors that may increase the risk for uterine perforation at time of surgical abortion (Shakir & Diab, 2013; Obed & Wilson, 1999; Grimes, et al., 2006):

• Uterine position—retroverted, acutely anteverted or retroflexed
• Infection
• Multiparity
• Multiple gestation
• Advanced gestational age
• Inadequate cervical preparation
• Difficult cervical dilation
• Uterine anomalies or cavity distorted by fibroids
• Previous cervical/uterine surgery, including cesarean section
• Provider inexperience
• Presentation for postabortion care (after unsafe abortion procedure)

Uterine perforation can occur at almost any step of the abortion process as instruments pass into the uterus.  Additionally, perforation may occur from a foreign object or implement used to perform an unsafe abortion.

The location of the perforation can be anywhere in the uterus, although the midline anterior or posterior surface of the fundus is the most common (Sharma, Malhotra & Pundir, 2003). Uterine perforation often goes undetected and resolves without the need for intervention for people who have procedures before 13 weeks (Kaali, Szigetvari & Bartfai, 1989; Sharma, Malhotra & Pundir, 2003). For example, perforation with a small, blunt instrument in the fundus is likely to cause no problems, heal quickly, and need no additional management.  Lateral uterine perforations are rare, but are particularly concerning, given the proximity of the branches of the uterine artery and risk for serious bleeding (Berek & Stubblefield, 1979).

Diagnosis

A provider should suspect uterine perforation when a sudden loss of resistance occurs during cervical dilation or vacuum aspiration, allowing an instrument to pass well beyond the expected length of the uterus. If available, ultrasound may be a helpful diagnostic aid (Coughlin et al., 2013; Crosfil & Hughes, 2006; Gakhal & Levy, 2009; Shalev, Ben-Ami & Zuckerman, 1986; Skolnick, Katz & Lancet, 1982).

Uterine perforation can be visualized during laparoscopy and laparotomy. A provider does not need to definitively diagnose a perforation if the patient is stable and the concern for intra-abdominal injury is low. If a provider sees yellow fatty tissue in the uterine aspirate, their suspicion for uterine perforation and bowel injury should be high and the individual should be referred for immediate surgical management whether stable or not. Prompt recognition and management of injury to abdominopelvic viscera (bowel, bladder, blood vessels, etc.) resulting from uterine perforation is necessary to avoid serious complications (Obed & Wilson, 1999; Amarin & Badria, 2005).

Management

In many cases, providers can manage uncomplicated uterine perforation before 13 weeks gestation conservatively by observing for any changes in clinical status (Moburg, 1976; Freiman & Wulff, 1977; Grimes, Schultz & Cates, 1984; Mittal & Misra, 1985; Chen, Lai, Lee & Leong, 1995; Lindell & Flam, 1995; Peterson et al., 1983; Pridmore & Chambers, 1999). Providers should have a higher level of suspicion for intra-abdominal injury when a perforation occurs during an abortion at or after 13 weeks or during dilation and evacuation; these patients should be promptly referred for further evaluation as additional treatment may be warranted (Darney, Atkinson & Hirabayashi, 1990).

If there is concern for damage to abdominopelvic viscera, including bowel, but the individual is stable, and the experience and equipment are available, then laparoscopy is the investigative method of choice. With obvious bowel damage or herniation through the uterine defect, excessive bleeding, or hemodynamic instability, immediate laparotomy may be preferable (Lauersen & Birnbaum, 1973; Grimes, Schultz & Cates, 1984; Chen et al., 1995; Lindell & Flam, 1995; Kumar & Rao, 1998; Obed & Wilson, 1999). If the abortion was not completed, the uterus should be evacuated under direct visualization at the time of laparoscopy or laparotomy (Lauersen & Birnbaum, 1973; Goldschmitt et al., 1995; Chen, Lai, Lee & Leong, 1995).  No evidence is available to support the safety or effectiveness of medical management to complete uterine evacuation immediately following suspected or confirmed uterine perforation.

Providers at health centers without available operating theaters or expertise should have clear protocols for resuscitation and transfer to a higher level of care. Patients at risk of shock require intravenous line placement, supplemental oxygen, fluid resuscitation and replacement of blood products as indicated.

References

Amarin, Z.O. & Badria, L.F. (2005) A survey of uterine perforation following dilatation and curettage or evacuation of retained products of conception. Archives of Gynecology and Obstetrics, 271(3), 203-6.

American College of Obstetricians and Gynecologists. (2019). Second-trimester abortion: ACOG Practice Bulletin No. 135. Obstetrics & Gynecology, 121(6), 1394-406.

Berek J.S. & Stubblefield, P.G. (1979). Anatomic and clinical correlates of uterine perforation. American Journal of Obstetrics and Gynecology, 135(2), 181-4.

Chen, L.H., Lai, S.F., Lee, W.H., & Leong, N.K. (1995). Uterine perforation during elective first trimester abortions: A 1 year review. Singapore Medical Journal, 36(1), 63–7.

Coughlin, L.M., Sparks, D.A., Chase, D.M., & Smith, J. (2013). Incarcerated small bowel associated with elective abortion uterine perforation. Journal of Emergency Medicine, 44(3), e303-306.

Crosfill, F.M., & Hughes, S. (2006). Ultrasound scan appearance of perforated uterus after surgical evacuation of retained products of conception. Journal of Obstetrics and Gynaecology, 26(3), 278–9.

Darney, P.D., Atkinson, E., & Hirabayashi, K. (1990). Uterine perforation during second-trimester abortion by cervical dilation and instrumental extraction: A review of 15 cases. Obstetrics & Gynecology, 75(3 Pt 1), 441–4.

Freiman, S.M., & Wulff, G.J. (1977). Management of uterine perforation following elective abortion. Obstetrics & Gynecology, 50(6), 647–50.

Gakhal, M.S., & Levy, H.M. (2009). Sonographic diagnosis of extruded fetal parts from uterine perforation in the retroperitoneal pelvis after termination of intrauterine pregnancy that were occult on magnetic resonance imaging. Journal of Ultrasound  in Medicine28(12):1723–7.

Grimes, D.A., Schulz, K.F., & Cates WJ. (1984) Prevention of uterine perforation during curettage abortion. The Journal of the American Medical Association, 27;251(16), 2108–11.

Grimes, D.A., Benson, J., Singh, S., Romero, M., Ganatra, B., Okonofua, F.E., & Shah I.H. (2006). Unsafe abortion: the preventable pandemic. The Lancet, 368(9550), 1908-19.

Goldschmit, R., Elchalal, U., Dgani, R., Zalel, Y., & Matzkel, A. (1995). Management of uterine perforation complicating first-trimester termination of pregnancy. Israel Journal of Medical Sciences, (4), 232-4.

Kaali, S.G., Szigetvari, I.A., & Bartfai, G.S. (1989). The frequency and management of uterine perforations during first trimester abortions. American Journal of Obstetrics & Gynecology, 161(2), 406–8.

Kerns, J., & Steinauer, J. (2013). Management of postabortion hemorrhage. Contraception, 87(3), 331-42.

Kumar, P., Rao, P. (1988). Laparoscopy as a diagnostic and therapeutic technique in uterine perforations during first trimester abortions. Asia–Oceania Journal of Obstetrics and Gynaecology, 14(1), 55–9.

Lauersen, N.H., Birnbaum, S. (1973). Laparscopy as a diagnostic and therapeutic technique in uterine perforations during first trimester abortions. American Journal of Obstetrics & Gynecology, 117(4), 522-6.

Lindell, G., Flam, F. (1995). Management of uterine perforations in connection with legal abortions. Acta Obstetricia et Gynecologica Scandinavica, 74(5), 373–5.

Mittal, S., Misra, S.L. (1985). Uterine perforation following medical termination of pregnancy by vacuum aspiration. International Journal of Gynaecology and Obstetrics, 23(1), 45–50.

Moberg, P.J. (1976). Uterine perforation in connection with vacuum aspiration for legal abortion. International Journal of Gynaecology and Obstetrics, 14(1), 77–80.

Obed, S.A., & Wilson, J.B. (1999). Uterine perforation from induced abortion at Korle Bu Teaching Hospital, Accra, Ghana: A five year review. West African Journal of Medicine, 18(4), 286–9.

Peterson,W.F., Berry, N., Grace, M.R., Gulbranson, C. L. (1983). Second-trimester abortion by dilatation and evacuation: an analysis of 11,747 cases. Obstetrics  & Gynecology, 62(2), 185-190.

Pridmore, B.R, & Chambers, D.G. (1999). Uterine perforation during surgical abortion: a review of diagnosis, management and prevention. Australian and New Zealand Journal of Obstetrics and Gynaecology, 39(3), 349–53.

Shakir, F, & Diab, Y. (2013). The perforated uterus. The Obstetrician & Gynaecologist, 15(4), 256-61.

Shalev, E., Ben-Ami, M., & Zuckerman, H. (1986). Real-time ultrasound diagnosis of bleeding uterine perforation during therapeutic abortion. Journal of Clinical Ultrasound, 14(1), 66–7.

Sharma, J.B., Malhotra, M., & Pundir, P. (2003). Laparoscopic oxidized cellulose (Surgicel) application for small uterine perforations. International Journal of Gynaecology and Obstetrics, 83(3), 271–5.

Skolnick, M.L., Katz, Z., & Lancet, M. (1982). Detection of intramural uterine perforation with real-time ultrasound during curettage. Journal of Clinical Ultrasound, 10(7), 337–8.