Delayed presentation of uterine perforation

Uterine Perforation as a Complication of the Intrauterine Procedures Causing Omentum Incarceration: A Review

OBJECTIVE

Omentum involvement resulting from uterine perforation is a rare complication following intrauterine procedures that might require immediate intervention due to severe ischemic consequences. This review examines the prevalence of this complication, risk factors, the mode and timing of diagnosis, the proper management and the outcome.

METHODS

A systematic literature search was conducted on PubMed, PubMed Central and Scopus using uterine perforation, D&C, abortion and omentum as keywords. The exclusion criteria included the presence of the uterus or placenta's malignancy and uterine perforation following delivery or caused by an intrauterine device.

RESULTS

The review included 11 articles from 133 screened papers. We identified 12 cases that three evaluators further analysed. We also present the case of a 32-year-old woman diagnosed with uterine perforation and omentum involvement. The patient underwent a hysteroscopic procedure with resectioning the protruding omentum into the uterine cavity, followed by intrauterine device insertion.

CONCLUSION

This paper highlights the importance of a comprehensive gynaecological evaluation following a D&C procedure that includes a thorough clinical examination and a detailed ultrasound assessment. Healthcare providers should not overlook the diagnosis of omentum involvement in the presence of a history of intrauterine procedures.

OUP accepted manuscript

Uterine perforation is a rare complication of abortion. It becomes much rarer when associated with a small bowel incarceration at the uterine breach. Its diagnosis can be suspected clinically, but radiology remains more sensitive for diagnosis. Surgery is the cornerstone in treating this entity as it provides both diagnostic and therapeutic management. A multidisciplinary therapeutic approach should be immediately performed to ensure a good prognosis. In this report, we describe a case of small intestine incarceration in the breach of a uterine perforation that occurred in the weeks following a clandestine abortion.

Detrimental Pneumoperitoneum and Bowel Necrosis Secondary to Dilatation and Curettage: Necessitating the Importance of Healthcare Awareness

We have read about numerous cases depicting life-threatening fatalities due to the lack of awareness and accessibility to health care facilities. A 23-year-old pregnant woman in a village in India underwent a dilation and curettage procedure for spontaneous abortion by an uncertified medical practitioner. Eventually, she presented to the emergency room with ER and an initial abdominal X-ray was consistent with the finding of free air under the diaphragm/pneumoperitoneum and air-fluid levels. Here we present a case of bowel perforation secondary to being strangulated within the uterine cavity.

Imaging evaluation of uterine perforation and rupture

Uterine perforation and rupture, denoting iatrogenic and non-iatrogenic uterine wall injury, respectively, are associated with substantial morbidity,and at times mortality. Diverse conditions can result in injury to both the gravid and the non-gravid uterus, and imaging plays a central role in diagnosis of such suspected cases. Ultrasound (US) is the initial imaging modality of choice, depicting the secondary signs associated with uterine wall injury and occasionally revealing the site of perforation. Computed tomography can be selectively used to complement US findings, to provide a more comprehensive picture, and to investigate complications beyond the reach of US, such as bowel injury. In certain scenarios, magnetic resonance imaging can be an important problem-solving tool as well. Finally, catheter angiography is a valuable tool with both diagnostic and therapeutic capability, with potential for fertility preservation. In this manuscript, we will highlight the clinical and imaging approach to uterine perforation and rupture, while emphasizing the value of various imaging modalities in this context. In addition, we will review the multi-modality imaging features of uterine perforation and rupture and will address the role of the radiologist as a crucial member of the management team. Finally, a summary diagrammatic depiction of imaging approach to patients presenting with uterine perforation or rupture is provided.

Omental Incarceration over Twenty Years Presenting as a Hyperechoic Endometrial Mass in a Postmenopausal Woman

Uterine perforation related with dilatation and curettage (D&C) is an uncommon event. Combined complications such as hemorrhage, adjacent organ injury, and omental incarceration may require an emergent surgical treatment. These are usually evident immediately or several days after the D&C, and a delayed presentation of uterine perforation are extremely rare. Herein, we report a rare case of omental incarceration presenting as a hyperechoic endometrial mass in a postmenopausal woman, diagnosed twenty-three years after the D&C. According to this case, when we encounter a hyperechoic endometrial lesion penetrating the uterine wall in women with a history of an intrauterine procedure such as D&C, we need to consider the possibility of an incarcerated omentum.

Hysteroscopic management of omentum incarceration secondary to uterine perforation: Case report and review of literature

Uterine perforation is a potential complication of intrauterine procedures that can be associated with vascular or visceral injury. We report the case of a 35-year-old woman diagnosed with omentum incarceration, secondary to a uterine perforation, during a dilatation and curettage. This rare complication was successfully managed by release of incarcerated omentum hysteroscopically. Sealing of uterine wall defect was achieved by administration of intravenous uterotonic drugs, thus, avoiding a major surgery. In conclusion, this is a novel approach to a case of uterine omental incarceration. To date, there are few cases reported in the literature and only one of them was managed by hysteroscopy. Hysteroscopy alone or combined hysteroscopic and laparoscopic approach when needed, should be attempted in such cases as it is safe and minimally invasive.

Bleeding in the retroperitoneal space under the broad ligament as a result of uterine perforation after dilatation and curettage: Report of a case

Uterine perforation, a complication of dilation and curettage, is typically recognized immediately after the procedure by clinical symptoms of peritoneal irritation resulting from intraperitoneal bleeding. Our patient complained of having an uncomfortable feeling, slight dizziness, palpitation in the sitting position and abdominal discomfort but did not show signs of peritoneal irritation 24 h after dilation and curettage. However, she suddenly complained of abdominal pain. Tenderness and rebound tenderness were detected at the lower abdominal wall. Ultrasonography and magnetic resonance imaging suggested uterine perforation. When the abdominal cavity was opened, a hematoma under the broad ligament of the uterus, laceration of the side wall of the uterine cervix and a small amount of bloody ascites and small clots in the abdominal cavity were observed. The uterine cervical wall was sutured. Physicians should postpone discharge and observe the clinical course carefully when a patient complains of inexplicable discomfort after dilation and curettage.

[Interest of multidetector CT virtual hysterosalpingography in the diagnosis of utero-peritoneal fistulas about 4 cases]

We report four cases of uterine fistula found with the multidetector CT virtual hysterosalpingography. Patients were received for suspicious of a utero-peritoneal fistula at hysterosalpingography. They were young people at childbearing age (average age of 33 years), multigravidae, two of whom were nulliparous, one primiparous and one multiparous. We noted a history of voluntary interruption of pregnancy by curettage and a cesarean section. For the opacification, we used the classic hysterography standard equipment by means of 1/5 diluted iodine with saline solution as contrast. The multidetector CT virtual hysterosalpingography revealed small uterine perforations including three which were located in uterine posterior face at cervico-isthmic area and corporeal area, bringing about a utero-peritoneal fistula. The multidetector CT virtual hysterosalpingography is a simple and powerful technique for the diagnosis of utero-peritoneal fistula. It is convenient and then deserves an important place in the evaluation of uterine fistula.

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.