EM@3AM: Uterine Perforation

Authors: Nour Sino, MD (Department of Emergency Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan) and Glenn Ekblad, DO, MSN, (Clinical Assistant Professor, Department of Emergency, Medicine Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Welcome to EM@3AM, an emDocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.


A 31 y/o female presents to the ED for acute lower abdominal pain that she rates at a 10/10. Six hours prior to arrival, the patient had a D&C for an elective abortion at 15 weeks gestation. She had a prior caesarean section two years ago. She has intermittent nausea but no vaginal bleeding, and she denies any recent blunt trauma.

VS: T: 98.8, HR 107, RR 20, BP 102/76, SpO2 98% on room air

Physical exam: Patient appears uncomfortable due to pain. There is tenderness to palpation in the suprapubic region, with guarding. Pelvic exam reveals scant vaginal blood and small clots present in the vaginal vault. Cervical-os is 1cm dilated, without active bleeding. There is no significant adnexal tenderness or cervical motion tenderness.

What is the diagnosis?

What is your next step for evaluation?

What is your management?


Diagnosis: Uterine Perforation

Uterine perforation is rare and usually occurs as a complication of intrauterine procedures such as IUD placement, D&C, or hysteroscopy.

– Incidence of 0.1-0.5% and seen mainly in postmenopausal women with a gynecological malignancy.5

– Risk factors for perforation include an inexperienced clinician performing intrauterine procedure, advanced age, increased parity, increased gestational age during D&C, and obesity.2

– Uterine perforation and bowel injuries are the major complications following unsafe abortions.7

– Incidence of uterine perforation with IUD insertion is 1 in 1,000 insertions.4

– The most common perforated site with D&C is the fundus, which is relatively avascular when compared to the lateral body and cervix.1

– May also occur spontaneously from a pyometrium, which is an accumulation of pus in the uterine cavity blocking drainage from the cervix.

– Complete perforation occurs through all uterine layers (endometrium, myometrium, and serosa), as compared to partial.4

– Complications include perforation into bowel wall or urinary tract (ureter and/or bladder), and hemoperitoneum.4,1

– Unrecognized uterine perforation may result in postoperative abdominal or pelvic pain beyond what is expected for post-operative recovery.3

– Differential diagnosis includes intra-abdominal pathology (abscess, infection, obstruction, etc.), PID, cystitis, torsion, stone, endometriosis, urinary retention, and uterine fibroid.8

 

Presentation: Heavy vaginal bleeding, abdominal distension, abdominal or pelvic pain, hematuria, nausea, and vomiting.3

Exam: Patients may present with varying symptoms and exam findings. Tachycardia, hypotension, fever, abdominal distension, rebound or guarding, abdominal tenderness, and vaginal bleeding can occur.

 

Evaluation:

  • Vital signs – monitor for tachycardia, hypotension, and tachypnea suggesting shock.
  • Abdominal exam – tenderness to palpation, peritoneal signs.
  • Pelvic exam – evaluate for vaginal bleeding, adnexal tenderness, mass, foreign bodies, IUD threads, or cervical motion tenderness.
  • Laboratory studies – consider CBC, CMP, urinalysis, PT/INR and aPTT, lactic acid, pregnancy test, type and screen.
  • Hemodynamically stable patients – Pelvic U/S is the imaging modality of choice. 1,4 *Note that perforation cannot be excluded or confirmed with any imaging study. Diagnosis is made primarily on clinical suspicion.7
  • If bladder or ureter injury is suspected, evaluate with intravenous urography and/or CT urography.6

 

Management:

– IV fluids, antiemetics, pain control, and blood products if necessary.

– Immediately consult for surgical exploration if: patient is hemodynamically unstable, intraperitoneal contents such as bowel or omentum are found at the cervix, there is suspicion for bowel injury, lateral wall perforation with uterine vessel injury.2

– Hemodynamically stable: OB/GYN consultation; Patients with no evidence of hemorrhage can be safely monitored without surgical exploration.2  Antibiotics are not indicated unless there is suspicion for infectious process (i.e. endometritis, peritonitis).

Antibiotics (a variety of options are available):

– Peritonitis: Ceftriaxone 1g IV daily and Flagyl 500mg IV q8hrs.

– Endometritis: Post-partum: Clindamycin 900mg q8hrs and Gentamicin 1.5mg/kg q8rs; Non-pregnant inpatient: Cefoxitin 2g IV q6hrs and Doxycycline 100mg PO/IV BID OR Outpatient: Ceftriaxone 250mg IM once and doxycylcine 100mg BID.      

 

Pearls:

– Maintain a high index of suspicion for uterine perforation with recent intrauterine procedure or manipulation.

– Early OB/GYN consultation is critical.

– Surgical exploration is warranted when there is hemodynamic instability, intraperitoneal contents such as bowel or omentum are found at the cervix, suspicion for bowel injury, lateral wall perforation with uterine vessel injury.2

 

References/Further Reading:

  1. Seol, H. J., & Ki, K. D. (2015). Rupture of uterine serosal hematoma: Delayed complication of uterine perforation.Clinical and experimental obstetrics & gynecology,42(3), 388-389.
  2. Patounakis, G., & Schlaff, W. (2012). Management of Uterine Perforation.Postgraduate Obstetrics & Gynecology,32(23), 1-7. doi:10.1097/01.pgo.0000425901.51473.a3
  3. Lobo, R. A., Gershenson, D. M., Lentz, G. M., & Valea, F. A. (2017). Endoscopy: Hysteroscopy and Laparoscopy: Indications, Contraindications, and Complications. Comprehensive Gynecology (190-204). Philadelphia, Pennsylvania: Elsevier.
  4. Rowlands, S., Oloto, E., & Horwell, D. (2016). Intrauterine devices and risk of uterine perforation: current perspectives.Open Access Journal of Contraception,19. doi:10.2147/oajc.s85546.
  5. Kutuk, M., Ozgun, M., & Uludag, S. (2013). Spontaneous uterine perforation due to pyometra.Journal of Obstetrics and Gynaecologoy ,33(3), 322-323. http://dx.doi.org.ezproxy.med.wmich.edu/10.3109/01443615.2012.754415.
  6. Esparaz, A. M., Pearl, J. A., Herts, B. R., LeBlanc, J., & Kapoor, B. (2015). Iatrogenic Urinary Tract Injuries: Etiology, Diagnosis, and Management.Seminars in Interventional Radiology,32(2), 195–208. http://doi.org/10.1055/s-0035-1549378.
  7. Sama, C., Aminde, L., & Angwafo, F. (2016). Clandestine abortion causing uterine perforation and bowel infarction in a rural area: a case report and brief review. BMC Research Notes. 9:98. doi 10.1186/s13104-016-1926-5 https://www.ncbi.nlm.nih.gov/pubmed/26880002
  8. Hang, B., Abnormal Uterine Bleeding, Ch 96, pages 619-625, in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, Ed by J.E. Tintinalli, et at., 8th Ed., Pub 2016, ISBN: 978-0-07-179476-3.

 

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