What is the recommended treatment for a uterus perforated during a dilation and curettage (D&C) procedure?

Management of Uterine Perforation During D&C

For uterine perforation during D&C, immediate management depends on perforation size and associated injuries: small perforations without organ injury can be managed expectantly with observation, while large defects or suspected bowel/vascular injury require immediate laparoscopy or laparotomy. 1

Immediate Intraoperative Assessment

When perforation is recognized during the procedure, immediately stop the D&C and assess the clinical situation:

• Determine perforation size and mechanism: Small perforations from dilators or curettes versus large defects from suction cannulas have different implications 2
• Evaluate for associated organ injury: Consider whether bowel, bladder, or major vessels may have been injured based on instrument depth and patient symptoms 1
• Monitor vital signs: Assess for signs of intra-abdominal bleeding (tachycardia, hypotension, peritoneal signs) 2

Management Algorithm Based on Clinical Presentation

Small Perforation Without Complications

• Expectant management is appropriate for small perforations (typically from sound or small dilator) when:
  • Patient is hemodynamically stable 2
  • No suspicion of bowel or bladder injury 1
  • Minimal intraperitoneal bleeding suspected 2
• Admit for observation with serial vital signs and abdominal examinations 2
• Most small perforations resolve spontaneously without long-term consequences 2

Large Perforation or Suspected Organ Injury

• Immediate surgical exploration is mandatory via laparoscopy or laparotomy 1, 2
• Laparoscopy is preferred when feasible for diagnostic assessment and potential repair 2
• Direct visualization allows identification of:
  • Extent of uterine defect 3
  • Bowel or omental injury/incarceration 3
  • Vascular injury requiring hemostasis 2

Uncertain Perforation Status

• If perforation is suspected but not confirmed, consider diagnostic laparoscopy rather than continued observation 1
• Imaging (ultrasound or MRI) can help identify omental incarceration or hematoma formation, though surgical exploration remains definitive 3

Common Pitfalls and Delayed Presentations

Critical caveat: Uterine perforation can present in a delayed fashion days to weeks after D&C, even when not recognized intraoperatively 2:

• Serosal hematoma rupture can occur up to 10 days post-procedure, causing acute hemoperitoneum 2
• Omental incarceration may present with persistent pain and bleeding weeks later 3
• Any patient with post-D&C abdominal pain, fever, or persistent bleeding requires evaluation for delayed perforation complications 2

Surgical Repair Techniques

When surgical intervention is required:

• Laparoscopic approach is preferred for most cases, allowing direct visualization and repair 2
• Debride involved tissue: Remove incarcerated omentum or necrotic tissue 3
• Primary repair of uterine defect with absorbable suture 3
• Laparotomy is reserved for:
  • Hemodynamic instability 2
  • Extensive bowel injury 1
  • Inability to complete repair laparoscopically 2

Post-Procedure Monitoring

Following conservative or surgical management:

• Serial hemoglobin measurements if bleeding suspected 2
• Continued observation for signs of infection or ongoing bleeding 2
• Follow-up imaging (ultrasound or MRI) can identify complications like hematoma formation 3
• Bimanual examination and transvaginal ultrasound at follow-up visits to assess healing 3

The key distinction is that while the guidelines discuss D&C risks in the context of cancer staging 1, the actual management of perforation follows standard surgical principles: small defects heal with observation, while significant injuries require immediate surgical intervention to prevent morbidity from hemorrhage, infection, or organ injury 2, 3.