Perforation of the uterus: symptoms, first aid, how dangerous the condition, therapies
A intrauterine operations and manipulations are performed by a doctor almost blindly. In 1% of cases of all interventions can occur, perforation of the uterus is a wound through the wall of the surgical tool.
The cause of trauma
The greatest danger from the point of view of injury to the uterine wall represent aborting and curette that have sharp side edges. At the same time can injure adjacent organs. Dilator hegar’s rounded on the end and has a greater thickness, so they can perforate the organ much more difficult. In 0.3% of cases, perforation of the uterus during the introduction of the Navy.
A leading cause of injury considered technically incorrect performance of intrauterine procedures. Perforation of the body wall may occur under the following operations:
- medical abortion;
- separate the medical-diagnostic curettage;
- introduction the intrauterine device.
It is believed that puncturing the wall of a healthy body is almost impossible: it is sufficiently elastic and durable. And in various diseases, the structure of the tissue is friable, fragile, therefore it becomes possible damage.
The risk of perforation of the uterus is increased in the following cases:
- acute or chronic inflammation – endometritis;
- fibroids of different localization;
- the scar after childbirth or artificial surgical interventions;
- frequent intrauterine interventions, including abortions and diagnostic curettage;
- the recent operation, which took less than six months;
- abortion period after 12 weeks of gestation;
- hypoplasia of the uterus;
- age especially during menopause;
- the deviation of the body backwards (retroverse);
- cancer of the endometrium.
Injury uterine probe are rare and do not lead to profuse bleeding. Dilator hegar’s dangerous only in case of gross manipulation and in marked inflection body of the uterus anteriorly or backward. If it perforated the wall, then a large hole bleeding profusely. But the greatest danger is posed by the curette and aborting, which accounted for up to 80% of traumatic perforations.
Introduction the intrauterine device is performed blindly, the accuracy of the procedure depends on the technique of the doctor and his tactile sensations. The cause of the perforation wall is that the uterus does not always coincide with the axis of the cervical canal. Sometimes in the lower segment of the wall is very thin, which is a risk factor. Additional risk arises during the installation of VMS earlier than 6 months after the birth and immediately after artificial abortion.
Perforation through the spiral occurs immediately after installation, and in the form of spontaneous effects in a certain period after administration. Sometimes it is detected when attempting to draw a spiral. In this case, the threads will be lost or difficult IUD removal.
Trauma spiral can occur at the introduction stage, if there was active contraction of the myometrium – expulse aimed at the expulsion means. While the neck is perforated, so that the axis of the cervical canal does not coincide with the axis of the uterus.
How to recognize the condition?
Based on the amount of damage defined classification of perforation of the uterus:
- Full, when the hole is formed through the entire thickness of the wall. It is uncomplicated and complicated. In the latter case, further injured the gland, epididymis, intestine, bladder and other adjacent organs.
- Incomplete in its serous covering is still intact.
In many cases, signs of perforation, the doctor may recognize directly at the time of its Commission. Perfect when curettage, perforation of the uterus is accompanied by an unexpected failure of the tool to a greater depth than that which was defined in the process of sensing. The tool is not obstructed by the walls of the organ. Sometimes this symptom is observed when a sudden atony, then you need to conduct a differential diagnosis with the perforation.
If there is a perforation, as a complication of induced abortion, increased bleeding, and part of the ovum cease to appear in the discharge substance. So start bleeding at the beginning of the curettage when the ovum still attached to the wall. Bleeding after the abortion, when removal of parts is already completed, the free movement in the abdominal cavity of a surgical tool, which is accompanied by signs of shock, confirm the presence of injury.
But atony, especially in frequently parous women or after repeated abortions, is also accompanied by massive bleeding and flabby uterus. Therefore, it is necessary to conduct differential diagnostics.
The greatest difficulties will cause perforation incomplete abortion. It can remain unnoticed for a gynecologist and the patient. In case of severe wound of the uterus with prolapse of omentum, bowel loops, the diagnosis does not cause difficulties.
In some cases the symptoms of perforation of the uterus appear after surgery, when a woman came out of the anesthesia. Then there are complaints of the following nature:
- sharp pain in the abdomen;
- bleeding from the vagina;
- weakness, dizziness, loss of consciousness;
- tachycardia with simultaneous drop in blood pressure;
- blanching of the skin.
If perforated, the wound covers the neighbouring organ, the symptoms of pathology are less noticeable or may not occur. It all depends on the volume of bleeding and blood flow into the abdominal cavity.
The symptoms of perforation appear at the time of injury. If not, you need an additional diagnosis if you have symptoms of acute abdomen.
A thorough history, if a woman comes with complaints from home. If she is still in hospital, to assume this complication after the intervention much easier.
Is a pelvic exam. In most cases there is bleeding from the vagina. In the case of a perforation of the helix of the thread will not be visible from the opening of the cervical canal. In some cases the threads are visible, but remove the spiral is impossible.
The injury can happen in the time of the hysteroscopy. In this case, the diagnosis is established by the following criteria:
- the extender device takes on more than it should, depth;
- it is impossible to create a high pressure within the cavity of the body;
- visible bowel loops or omentum.
Sudden pallor, tachycardia talking about the significant blood loss. Its severity is installed in the shock index Allgower. This pulse rate is divided by the systolic pressure. If the figures 0.8 and less, it says a little bleeding, to 50 ml, visible symptoms yet. Reduction of circulating blood volume by 20% is manifested as a shock index of 0.9 to 1.2. When this is poured out to 1250 ml of blood. Loss 30% of BCC increases the index to 1.3-1.4. The pattern of bleeding is accompanied by tachycardia up to 120 beats per minute, shortness of breath, sweating. A 40% loss of blood leads to stupor, pressure is critically low or not is determined. Shock index of 1.5 and above.
Poured into the abdominal cavity blood causes irritation of the peritoneum, so there are peritoneal symptoms. Abdominal pain increases with movement. The injury of the neighbouring hollow organs leading to rupture their contents into the cavity of the abdomen, which also leads to the development of peritonitis.
Ultrasound diagnostics allows to determine the free fluid in the abdominal cavity. If there is a perforation of the helix, in most cases, it can also be identified using ultrasound.
As you can use a diagnostic hysteroscopy. It identifies the visible damage, the position of the IUD.
Sometimes the spiral is not determined using ultrasound. In such cases, conduct x-ray examination. In the overview picture of the pelvic organs will be visible metal parts of the device.
Using the General analysis of blood can determine the level of erythrocytes, hemoglobin and hematocrit. These data are necessary for decision-making about the need for blood transfusions. Also be sure to determined blood group and RH factor.
If perforation has occurred at the stage of sounding the uterus, then further manipulation is stopped. Emergency treatment of perforation of the uterus, which was diagnosed during surgery, involves the insertion of uterotonics, applying hot water bottles, ice on the stomach. If the hole was made with a small instrument (probe), the ultrasound is no free fluid in the abdominal cavity is chosen expectant management. The woman remains under medical supervision in a hospital.
Treatment of perforation of the uterus in each case individually and depends on the severity of damage and overall condition. Through-hole in the wall of the organ with massive bleeding be surgical treatment. A relatively small defect is sutured using laparoscopic access. This minimally invasive surgery, which is performed under the control of a video camera introduced into the abdomen through a small hole in the abdominal wall (laparoscopy read more about, read our article at the link).
If the damage spiral led to its exit into the abdominal cavity, you need as quickly as possible to remove it, especially for copper IUDs. Copper ions lead to the inflammatory response. The manipulation is carried out laparoscopically. But if necessary, it is extended to a laparotomy. The patient before the operation informs that in case of a large number of adhesions in the abdominal cavity, injury to other organs, the operation will be changed.
Injury of other pelvic organs – bowel, bladder – requires the work of a surgeon, not a gynecologist.
With multiple large lesions of the uterus and if suturing of defects does not stop bleeding, resorted to an extreme method – amputation of the organ. Bleeding when injured vessels of the uterus is massive and frequently leads to disseminated intravascular coagulation. Therefore, in order to save the life of the patient, doctors have to go to extreme measures.
Treatment of acute blood loss depends on the degree of severity of the condition. Is shock treatment, as well as the restoration of circulating blood volume. For this purpose colloid and crystalloid solutions, which compensates for the deficiency due to the fluid and restore the ionic composition. Depending on the clinical situation, use a plasma, conduct a blood transfusion. If the bleeding only took place, it is possible to carry out reinfusion own blood collected from the abdominal cavity.
Antibiotics are prescribed obligatory in all cases of perforation. Selected drugs with broad spectrum of action of cephalosporin (Cefotaxime, Ceftriaxone), Gentamicin, for the prevention of anaerobic infections Metronidazole.
Rehabilitation and prevention
The consequences of the traumatization of the uterus depend on the amount of damage. Large perforated holes healed with scar formation. Woman injured after this is put on the account in female consultation.
Occurring after perforation of the uterus, the pregnancy may be complicated by:
- the weakness of labor;
- untimely discharge of amniotic fluid;
- risk of uterine rupture along the scar;
- bleeding in the postpartum period.
Pregnancy in these patients should be planned carefully. You must examination the consistency of the scar. Recommended to become pregnant not earlier than 2 years after the injury.
The consequences of perforation have different severity. Intervention in the abdomen often results in the formation of adhesions. To avoid possible injuries with proper prevention.
Particularly noteworthy are women from high-risk groups:
- With acute or chronic endometritis.
- With uterine scar after surgical interventions (caesarean section, myomectomy).
- Frequent intrauterine manipulation (abortion, diagnostic curettage).
- After a recent (less than 6 months) transactions.
Not to get into the risk group, you should follow several simple recommendations. Any infection should be treated with full course of antibiotics. This should be done in a timely manner to prevent the transition of acute forms to chronic.
To reduce the amount of interference to the surgical removal of myoma node, it is possible to apply drug therapy (medical castration). Under the influence of drugs that reduce estrogen level, units decrease, does not require large incisions on the uterus.
Avoid abortion and carefully choose means of contraception. Coitus interruptus is not one of them. The optimal method in each case can be discussed with your doctor.
Timely treatment of non-inflammatory diseases of the genital organs will reduce the likelihood of frequent scraping, dusting, and hence the risk of perforation in one of them.