What should I do if the uterus perforates during an evacuation procedure?

Management of Uterine Perforation During Evacuation Procedure

If uterine perforation occurs during an evacuation procedure, immediate surgical consultation is required while stabilizing the patient and preparing for potential laparotomy or laparoscopy to repair the defect and evaluate for injury to adjacent organs.

Immediate Actions After Identifying Perforation

• Stop the procedure immediately and stabilize the patient by monitoring vital signs for evidence of hemorrhage or shock 1
• Keep the area of perforation clean to prevent spillage of uterine contents into the peritoneal cavity 2
• Minimize additional carbon dioxide insufflation to avoid compartment syndrome 2
• Obtain urgent surgical consultation even if endoscopic repair might be technically feasible 2
• Administer broad-spectrum antibiotics to cover Gram-negative and anaerobic organisms 2

Assessment and Diagnostic Approach

• Evaluate for signs of peritonitis, which may indicate perforation with visceral injury 1
• Assess for hemodynamic instability (tachycardia, hypotension) which may indicate significant bleeding 1
• Consider imaging studies if the patient is stable:
  • Transvaginal ultrasound to assess the extent of perforation and potential intra-abdominal injury 2
  • CT scan may be necessary if there is concern for retroperitoneal injury or extensive intraperitoneal bleeding 2

Management Based on Clinical Presentation

For Hemodynamically Stable Patients:

• If the perforation is small (<2 cm) and no signs of visceral injury are present, conservative management with close monitoring may be considered 2
• Administer intravenous fluids and keep the patient nothing by mouth 2
• Continue broad-spectrum antibiotics 2
• Monitor for signs of deterioration including increasing pain, fever, or hemodynamic instability 1

For Hemodynamically Unstable Patients:

• Immediate surgical intervention is mandatory 2
• Resuscitate with intravenous fluids and blood products as needed 1
• Perform emergency laparotomy following damage control surgery principles 2
• Complete the evacuation procedure under direct visualization during surgery 3

Surgical Management Options

• Laparoscopy should be attempted first in stable patients to evaluate the extent of injury 2
• If laparoscopy is not feasible or the patient is unstable, proceed with laparotomy 2
• During surgery:
  • Evaluate for injury to adjacent organs (bowel, bladder, blood vessels) 3
  • Complete the evacuation procedure under direct visualization 3
  • Repair the uterine defect with appropriate suturing techniques 3
  • Consider uterine artery ligation or embolization for persistent bleeding 4

Special Considerations

• If omentum or bowel is visible through the cervical os or in the suction curette, this confirms perforation with potential visceral injury requiring immediate laparotomy 3
• For perforations with significant bleeding that cannot be controlled, bilateral uterine artery ligation via laparotomy or laparoscopic coagulation may be performed to preserve fertility 4
• In cases of intestinal injury with uterine perforation, prompt recognition and early intervention are crucial to reduce mortality, which can be as high as 10% 5

Post-Procedure Care

• Close monitoring for signs of infection, bleeding, or peritonitis 2
• Continue antibiotics for at least 24-48 hours 2
• Consider a water-soluble contrast study before initiating oral intake to confirm the absence of ongoing leakage 2
• Follow-up imaging may be necessary to ensure proper healing 2

Prevention of Future Complications

• Adequate training and supervision for those performing evacuation procedures 1
• Use of ultrasound guidance during difficult procedures to reduce the risk of perforation 2
• Appropriate patient selection and consideration of risk factors 1