Uterine perforation following medical termination of pregnancy by vacuum aspiration

An obscure cause of bowel obstruction: Jejunal herniation into uterine cavity

INTRODUCTION AND IMPORTANCE

Adhesions and external hernias are the two most common causes of small bowel obstruction. Perforation of organs within the abdomen or pelvis following manual vacuum aspiration is known to lead to an acute presentation.

CASE PRESENTATION

We report a case of a 33-year-old female with small bowel obstruction due to herniation of a loop of intestine through a uterine defect with symptoms starting 63 days following manual vacuum aspiration.

CLINICAL DISCUSSION

Intra-abdominal or pelvic perforations usually present immediately which makes our case unique as the patient started having symptoms 63 days post manual vacuum aspiration. The most feared complication of prolonged small bowel obstruction is ischaemia which may lead to perforation. In our case, it is plausible that jejunum partially herniated into the uterine cavity shortly after manual vacuum aspiration, forming a jejunal plug, leading to the delayed onset of symptoms. This delay in onset of symptoms might have led to progressive massive dilatation of the small bowel and subsequent ischaemic necrosis.

CONCLUSION

Detailed history taking is pertinent as bowel obstruction could still occur a prolonged period after manual vacuum aspiration. A double-contrast enhanced CT scan of the abdomen proves invaluable in the context of surgical planning and facilitating the collaboration of a multidisciplinary team, particularly when the underlying causes of bowel obstruction remain elusive upon initial presentation.

Suspected illegal abortion and unsafe abortion leading to uterine rupture and incomplete abortion: A case report

Introduction

Unsafe abortions are more prevalent in developing countries and countries with restrictive abortion laws, and can lead to significant maternal mortality. Usually, the presentation includes abdominal pain, fever and vaginal bleeding.

Case presentation

We reported the case of a female in her twenties in her second trimester of pregnancy following unsafe abortion. The patient had abdominal pain, and laboratory investigations revealed anemia and leucocytosis. The patient opted for abortion as the foetus was identified as female by a service provider. Due to unsafe and illegal abortion, the patient developed complications of incomplete abortion and uterine rupture. She was successfully managed by emergency laparotomy followed by repair of uterine rupture and symptomatic management.

Clinical discussion

Unsafe abortion can lead to complications such as incomplete abortion and uterine rupture. Complications due to abortion are more frequent if not performed by experienced surgeons. In our case, the manual vacuum and aspiration technique was used during the second trimester of pregnancy, which led to uterine perforation.

Conclusion

Our case highlighted the importance of safe abortion practices and the approach to clinical management of complications of unsafe abortion. Also, global health problems such as unsafe abortion, illegal abortion, sex-selective abortion, and violation of ethical conduct need to be addressed to curb unsafe abortion.

Cesarean Delivery Changes the Natural Position of the Uterus on Transvaginal Ultrasonography

OBJECTIVES

To assess whether cesarean delivery changes the natural position of the uterus.

METHODS

In this retrospective Institutional Review Board-approved cohort study, we conducted a search of our university gynecologic ultrasonography (US) database. Patients with transvaginal US images before and after either vaginal or cesarean delivery between 2012 and 2015 were included. Women with prior cesarean delivery were excluded. Two readers independently measured antepartum and postpartum flexion angles between the longitudinal axis of the uterine body and the cervix. We calculated intraclass correlation coefficients to measure inter-reader agreement. Antepartum and postpartum uterine flexion angles were compared between patients with vaginal and cesarean delivery.

RESULTS

We included 173 patients (107 vaginal and 66 cesarean delivery). The mean interval between scans ± SD was 18 ± 10 months. Inter-reader agreement for flexion angles was almost perfect (intraclass correlation coefficients: antepartum, 0.939; postpartum, 0.969; both P < .001). There was no difference in mean antepartum flexion angles for cesarean delivery (154.8° ± 45.7°) versus vaginal delivery (145.8° ± 43.7°; P = .216). Mean postpartum flexion angles were higher after cesarean delivery (180.4° ± 51.2°) versus vaginal delivery (152.8° ± 47.7°; P = .001. Differences in antepartum and postpartum flexion angles between cesarean and vaginal delivery were statistically significant (25.6° versus 7.0°; P = .027).

CONCLUSIONS

Cesarean delivery can change the uterine flexion angle to a more retroflexed position. Therefore, all women with a history of cesarean delivery should undergo a transvaginal US examination before any gynecologic surgery or intrauterine device placement to reduce the possibility of surgical complications.

Small bowel exteriorisation after uterine perforation from manual vacuum aspiration for abortion in a young cameroonian: a case report

Manual vacuum aspiration is an effective and safer surgical method of uterine evacuation for an abortion. Nonetheless, it can present some life-threatening complications like uterine perforations. In a uterine perforation the suction cannula is thought to be usually involved in the perforation and the resulting intraabdominal organ damage. We presented a case of a young muilti-parous Cameroonian woman who was underwent a manual vacuum aspiration for a first trimester incomplete abortion, and which was complicated by a fundal uterine perforation with exteriorisation of small bowels through the vagina.

Uterine perforation as a complication of surgical abortion causing small bowel obstruction: a review

OBJECTIVE

Small bowel obstruction after unrecognized or conservatively treated uterine perforation is extremely rare. It is a surgical emergency and the delay in diagnosis and treatment has deleterious consequences for the mother. The purpose of this study is to critically review the available literature and ascertain the level of evidence for the mechanisms, diagnosis and management of small bowel obstruction after uterine perforation due to surgical abortion.

METHODS

Systematic literature search was conducted in Pubmed (1946 to 2012) and Pubmedcentral (1900 to 2012) including all available English and French language fulltext articles. Three evaluators reviewed and selected all available case reports and case series. Search terms included small bowel obstruction, bowel obstruction, bowel incarceration, bowel entrapment, vaginal evisceration, uterine perforation, uterine rupture, and abortion. The exclusion criteria were (1) complex injuries where small bowel incarceration was present but with bleeding and/or bowel perforation as the leading symptomatology; (2) articles only numbering the patients without details on the topic. Analyses of incidence, risk factors, mechanisms of the disease, time of clinical presentation, diagnostic modalities, treatment, and maternal outcome were included.

RESULTS

Of the 73 articles screened 30 cases of small bowel obstruction were included in the review forming incidence, risk factors, and mechanisms of the disease, diagnosis, therapy, and maternal outcome.

CONCLUSIONS

A systematic review defined four mechanisms of small bowel obstruction after transvaginal instrumental uterine perforation with significant variations in clinical presentation and time of presentation. Duration of symptoms depend on the mechanism of small bowel obstruction. Vaginal evisceration is surgical emergency and treatment is mandatory without diagnostic workup. Survival rate during last century is 93 %. Multicentric trials and publication of all such cases are needed to determine algorithms for diagnosis and management of small bowel obstruction caused by instrumental uterine perforation.

Iatrogenic orifice transluminal endoscopic surgery (IOTES): managing uterine perforations at operative hysteroscopy

OBJECTIVE

To prove safety and feasibility of an intra-abdominal endoscopic evaluation via an iatrogenic uterine perforation that occurred during operative hysteroscopy.

DESIGN

Clinical case report.

SETTING

University Hospital.

PATIENT(S)

A multimorbid woman with postmenopausal bleeding with iatrogenic uterine perforation during hysteroscopic resection of an endometrial polyp.

INTERVENTION(S)

Intra-abdominal endoscopic evaluation via the iatrogenic uterine perforation site with use of a standard diagnostic hysteroscope.

MAIN OUTCOME MEASURE(S)

Visibility, technical feasibility, clinical course, and hematologic follow-up of the patient.

RESULT(S)

A sufficient assessment of the intra-abdominal cavity and the uterine defect was possible with use of a small-diameter diagnostic hysteroscope during the workup of an iatrogenic uterine perforation. No additional intervention-related side effects occurred.

CONCLUSION(S)

This technique was safe and feasible to gain operative access to the abdominal cavity, allowing a complete diagnostic intra-abdominal inspection for lesions of the adjacent organs. IOTES bears the potential to become a time-saving low-risk alternative to diagnostic standard laparoscopy.

A survey of uterine perforation following dilatation and curettage or evacuation of retained products of conception

STUDY

Of 11,914 women who underwent dilatation and curettage over a 7-year period (1995-2002) at Princess Badea Teaching Hospital in Irbid, North Jordan, 23 patients sustained a uterine perforation. In 22 cases, the operator was a trainee. Previous gynaecological surgery had been performed in only 2 of these 23 women.

CONCLUSION

Operator inexperience seemed to be the only risk factor in this very common operation.

[About two cases of uterine rupture outside of labour: consequences of an unnoticed previous perforation]

The uterine mute perforation following uterine evacuation of pregnancy exists; the obstetrical consequences of these are quite unknown. We report 2 cases of pregnancy complicated by uterine rupture and defect after uterine mute perforation. The physical signs are late and misleading. The notion of perforation during the instrumental evacuation of pregnancy must be mentioned for an adequate follow-up. Management thus remains essentially preventive.

Delayed presentation of uterine perforation

A 30-year-old woman presented to the emergency department with nonspecific abdominal pain 17 days after voluntary vacuum aspiration interruption of a first-trimester pregnancy. Physical examination and laboratory evaluation demonstrated mild diffuse abdominal tenderness without peritoneal signs and a mildly increased WBC count, respectively. When the patient's condition failed to improve she was admitted, and exploratory laparotomy was performed 5 days later. It revealed two uterine perforations, one of which contained incarcerated omentum with associated ischemic small bowel and complete small-bowel obstruction. Although uterine perforation with intraabdominal injury is a well-described complication of vacuum aspiration termination of pregnancy, most postabortion perforations go undetected. Delayed presentation of an acute complication is rarely observed.

Infectious osteitis pubis in an HIV seropositive female

We report a case of infectious osteitis pubis following a first trimester abortion in a female seropositive for the human immunodeficiency virus (HIV). Joint aspiration yielded Pseudomonas aeruginosa and the patient was successfully treated with oral ciprofloxacin.

The frequency and management of uterine perforations during first-trimester abortions

The frequency and management of uterine perforation during first-trimester abortions remain a matter of continuing debate among gynecologists. The rate of uterine perforations was 1.3/1000 procedures (eight cases) in 6408 women undergoing first-trimester abortions at our clinic. We also performed 706 first-trimester abortions at the time of laparoscopic sterilization. Two perforations (2.8/1000 procedures) were reported before laparoscopy. Twelve (15.6/1000 procedures) unsuspected perforations were discovered during direct laparoscopic visualization. This represents a 19.8/1000 procedure rate of perforation (14 cases). All 22 patients with perforations were managed conservatively, and no immediate or late complications were noted. Our data suggest that the true incidence of uterine perforations is significantly underestimated and serious complications caused by perforations are rare. Conservative therapy is recommended rather than early surgical intervention.