INTRODUCTION — Uterine perforation is a potential complication of all intrauterine procedures and may be associated with injury to surrounding blood vessels or viscera (bladder, bowel) [1,2]. In addition, uterine perforation and associated complications can result in hemorrhage or sepsis. The risk of uterine perforation is increased by factors that make access to the endometrial cavity difficult (eg, cervical stenosis, severe anteflexion, or retroflexion) or alter the strength of the myometrial wall (eg, pregnancy, lactation, menopause, or previous uterine disruption).
The prevention, diagnosis, and management of uterine perforation during gynecologic procedures will be reviewed here. Other complications of uterine surgery are discussed separately. (See "Complications of gynecologic surgery" and "Overview of hysteroscopy" and "Overview of pregnancy termination".)
Uterine perforation — The incidence of uterine perforation is generally based upon self-report by surgeons. In addition, many perforations are not recognized or confirmed, so it is likely that any reported incidence is an underestimate.
In most studies, hysteroscopy is complicated by confirmed uterine perforation in approximately 1 percent of operative procedures. There are fewer perforations during diagnostic hysteroscopy. (See "Overview of hysteroscopy", section on 'Uterine perforation'.)
During dilation and curettage (D&C) for disorders not related to pregnancy, perforation has been reported in approximately 0.3 percent of premenopausal patients and 2.6 percent in postmenopausal patients.
For pregnancy-related procedures, the risk of perforation is increased. It is most common when attempting control of postpartum hemorrhage after a third-trimester delivery (as high as 5 percent). For both first- and second-trimester procedures (for induced or spontaneous abortion), the rate of uterine perforation is approximately 0.5 percent. (See "Overview of pregnancy termination", section on 'Uterine perforation'.)
Endometrial ablation complicated by uterine perforation has been reported in approximately 1 percent of procedures; the rate is higher for endometrial resection (2 percent or higher). (See "Overview of endometrial ablation", section on 'Uterine perforation'.)
Uterine perforation can also occur in office-based procedures, including intrauterine device insertion and endometrial biopsy. The relevant data are presented separately. (See "Intrauterine contraception: Management of side effects and complications" and "Endometrial sampling procedures".)
Associated hemorrhage or visceral injury — There are few studies regarding the proportion of uterine perforations that result in hemorrhage or injury to surrounding structures. Data from three of the largest series include a total of 92 uterine perforations complicated by 16 cases of hemorrhage and 6 injuries to bowel or bladder [3-5].
Incarceration of the fallopian tube within the uterine perforation defect has also been described in patients after D&C for pregnancy termination or retained placenta [6-8].
RISK FACTORS — Uterine perforation occurs most often during mechanical cervical dilation or insertion of a sharp uterine instrument [3-5,9,10]. Factors that make access to the endometrial cavity difficult or alter the strength of the myometrial wall may predispose to uterine perforation, including [4,11]:
●Distortion or scarring of the endocervical canal (eg, due to previous cone biopsy or cesarean birth).
●Uterine malposition (eg, extreme anteversion, anteflexion, retroversion, or retroflexion).
●Distortion of uterine anatomy (eg, due to fibroids, intrauterine adhesions, previous uterine surgery, or congenital conditions [eg, unicornuate uterus], and diethylstilbestrol exposure resulting in reduced uterine size).
●Pregnancy or lactation.
●Menopausal endometrial atrophy and myometrial thinning.
●Menopausal vaginal atrophy and stenosis.
In addition, a lack of surgical experience, extensive operative procedures (eg, resection of fibroids or intrauterine adhesions), and, for pregnancy-related procedures, underestimation of gestational age, have been associated with a higher risk of uterine perforation [3,5,12-14].
Informed consent — Patients who are planning a procedure that involves intrauterine instrumentation should be counseled about the risk of uterine perforation and, if perforation should occur, the possibility of additional procedures (laparoscopy or laparotomy). This discussion should be documented on the procedure consent form and in the medical record. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Informed consent and patient expectations'.)
Preprocedure evaluation — Risk factors for uterine perforation may be suggested or confirmed during the preprocedure history and physical examination. As an example, patients with potential cervical stenosis include those who have never had a vaginal birth and postmenopausal patients. Similarly, there is a high risk for abnormalities of the endocervical canal in patients who have had surgical procedures involving the cervix including loop electrosurgical excision procedure, cervical conization, and cerclage. (See "Cervical intraepithelial neoplasia: Diagnostic excisional procedures".)
For procedures that are performed under local or no anesthesia, in our experience, endometrial access may be difficult in patients with anxiety and resultant severe levator ani muscle tension.
Cervical preparation — Cervical preparation, particularly in patients at high risk of uterine perforation (eg, cervical stenosis, postmenopausal), may facilitate mechanical dilation and/or insertion of instruments into the uterine cavity. This can be accomplished with a prostaglandin (eg, misoprostol, dinoprostone) or osmotic dilators (eg, laminaria). Misoprostol, in our experience, is more useful than dilators, particularly in patients with stenosis of the external os.
In a randomized trial including 130 nulliparous adolescents undergoing levonorgestrel intrauterine device (IUD) insertion, preprocedure administration of dinoprostone compared with placebo resulted in lower (ie, improved) patient pain scores and easier insertion of the IUD .
Cervical preparation for gynecologic procedures is discussed in detail separately. (See "Overview of hysteroscopy", section on 'Cervical preparation and dilation' and "Pregnancy termination: Cervical preparation for surgical procedures" and "Intrauterine contraception: Insertion and removal", section on 'Misoprostol' and "Dilation and curettage", section on 'Cervical preparation'.)
Treatment of vaginal atrophy — Severe vaginal atrophy and stenosis can make speculum insertion and full opening difficult. In addition, the ability to manipulate instruments, including dilators, and to angle them appropriately for access to the uterine cavity may be impaired. Pretreatment with vaginal estrogen therapy for one to two weeks before attempting a procedure will make the patient considerably more comfortable and may result in markedly improved access for visualization and sampling (see "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment"). In patients for whom estrogen therapy is contraindicated, topical anesthetic cream applied to the introitus and vulva by the patient at home or in the office several minutes prior to the procedure will be helpful in controlling the patient's discomfort and reducing secondary levator spasm.
Vaginoscopy without speculum insertion can also result in better and more comfortable entry through the cervical canal. To accomplish this without use of a tenaculum will require cervical preparation. Easier, more comfortable access may reduce the risk of perforation in postmenopausal patients with severe atrophy.
Preventive measures during the procedure — Uterine perforation commonly occurs during cervical dilation or insertion of a sharp operative instrument [3-5,9,10].
Uterine position — Perforation may result if cervical dilators are placed in the incorrect axis or with excessive force. Prior to beginning the procedure, a pelvic bimanual examination should be performed with careful attention to the uterine position to facilitate accurate placement of dilators. In patients with obesity, a rectovaginal examination may be needed to accurately determine if significant flexion of the uterus is present. (See "The gynecologic history and pelvic examination", section on 'Bimanual examination'.)
Straightening the uterine axis will also facilitate placement of cervical dilators and other instruments through the endocervical canal into the uterus. This can be accomplished by placing a tenaculum on the anterior lip of the cervix and using gentle traction. An intracervical or paracervical block may improve patient experience with difficult dilation in a flexed uterus. Rarely (typically for extremely anxious patients or patients without prior vaginal penetration) regional or general anesthesia may be required. Use of tapered dilators will result in more gentle mechanical dilation. (See "Pudendal and paracervical block" and "Overview of hysteroscopy", section on 'Pain management'.)
Difficult cervical dilation — Difficult cervical dilation can also be approached by using smaller instruments for dilation (eg, os finder, lacrimal duct probe, or urologic dilators).
If the cervix cannot be dilated using gentle force, ultrasound guidance may be required to safely dilate the cervix and gain passage into the endometrial cavity . There are no data evaluating this approach, but we find it useful in our clinical practice. (See "Dilation and curettage", section on 'Challenging cases'.)
In the rare instance of external os stenosis, local anesthetic can be injected into the cervix and a #11 scalpel blade used to incise the region of the os; this generally facilitates access to the cervical canal and endocervix.
Intracervical injection of dilute vasopressin (4 units per 80 mL normal saline) has also been reported to facilitate cervical dilation . Although generally well tolerated, vasopressin injection must be performed with caution since intravascular injection or absorption has been associated with profound hypertension, bradycardia, and intraoperative mortality . Due to this rare but serious complication, vasopressin injection is not recommended in the office setting. (See "Overview of hysteroscopy", section on 'Cervical preparation and dilation'.)
Safe use of operative instruments — Safe use of transcervical instruments that are passed blindly depends upon knowledge of uterine position and use of appropriate pressure, as noted in the preceding sections. The ability to directly visualize hysteroscopic instruments allows for additional safety measures. As an example, a resectoscopic loop should always be moved towards the operator, and not pushed into the uterine wall . Also, energy sources should not be activated unless there is a clear view of the instrument.
PERIOPERATIVE PRESENTATION OF UTERINE PERFORATION
During the procedure — Uterine perforation can be diagnosed during the perioperative period by direct visualization during the procedure or be suspected based on sudden loss of resistance or clinical signs of visceral or vascular injury. In addition, perforation should be suspected when a uterine sound, dilator, or operating instrument passes beyond the expected length of the uterus. The most common site of uterine perforation is the fundus [11,20].
Perforation at the fundus typically leads to minimal bleeding, whereas a lateral uterine perforation may lacerate uterine blood vessels, resulting in immediate and profuse hemorrhage and, possibly, a broad ligament hematoma. A low cervical perforation can lacerate the descending branch of the uterine artery, which can also present with delayed cervical bleeding if the artery initially goes into spasm.
During hysteroscopy, signs of possible injury to the myometrium include excessive bleeding from the uterus, loss of visualization due to sudden loss of uterine distension, and an abrupt increase in the distending fluid deficit. Any of these signs should prompt a careful search for perforation.
Direct visualization of any of the following confirms a uterine perforation:
●A hole in the uterine wall is directly visualized via hysteroscopy, laparoscopy, or laparotomy.
●Omentum (or other adipose tissue) or bowel is visible through an opening in the myometrium, or is present in the endometrial cavity or in a suction instrument (figure 1).
●Adipose tissue is identified in a curettage specimen by direct visualization by the surgeon or pathologist. Adipose tissue is present in the peritoneal cavity, but not within the uterus.
In the absence of direct visualization of an opening or concern based on passage of an instrument beyond the fundal length, uterine perforation should be suspected if there are signs of visceral or vascular injury. These include excessive bleeding, hypotension, or acute onset of hematuria. Occult retroperitoneal or intraabdominal hemorrhage can also occur, with perioperative hypotension the first sign of a complication.
If a perforation is suspected during the procedure, the procedure should be halted immediately, and all instruments removed. The patient should be carefully monitored in the recovery room for deterioration in vital signs or active bleeding.
Postprocedure clinical manifestations — Uterine perforation is generally recognized during the procedure. However, a patient with the following signs or symptoms after an intrauterine procedure should be evaluated for uterine perforation:
●Severe or persistent pelvic or abdominal pain
●Heavy or persistent vaginal bleeding
Many patients experience mild to moderate cramping for several hours after a uterine procedure. However, severe or persistent abdominal pain is unusual and requires prompt evaluation. One series of 15 patients who developed uterine perforations during second trimester dilation and evacuation reported that unexpected pain was the most prominent sign . The pain may be focal or diffuse since its source may be a specific injury to the uterus, bowel, or bladder.
Bowel may be perforated or become incarcerated in the uterine defect . Patients with bowel injuries may not develop symptoms for several hours or even days. Such injuries should be suspected if a patient has abdominal distension or continues to have abdominal pain, especially in the presence of tachycardia. Patients with bowel injury rarely present with rectal bleeding. Unrecognized bowel injury can be rapidly fatal. (See "Overview of gastrointestinal tract perforation".)
Evaluation — A uterine perforation that is not complicated by bleeding or injury to surrounding structures may require only observation, while a more involved perforation is a surgical emergency.
If uterine perforation is suspected, the patient should be evaluated with vital signs and a pelvic and abdominal examination. If occult bleeding is suspected due to deterioration in vital signs, laboratory evaluation should include a hematocrit and coagulation tests.
Uterine perforation cannot be confirmed or excluded with any imaging study, and thus, imaging is not a routine part of the evaluation. In patients with signs of hypovolemia without apparent bleeding, a pelvic ultrasound can be used to assess for a broad ligament or retroperitoneal hematoma.
If there is any concern for ureteral or bladder injury, the integrity of these structures can be easily assessed by the intravenous administration of one of several dyes or by direct visualization. In addition, a catheter or cystoscope can be introduced into the bladder to look for the perforation or fresh blood from an intravesical hemorrhage. Cystoscopy is required to visualize the ureteral orifices and assess for bilateral flow.
If bowel injury is suspected, abdominal exploration is warranted for diagnosis and potential repair. Evaluation of the bowel should be performed by a surgeon experienced in detection of bowel injury.
Management — Patients with suspected uterine perforation may be managed expectantly or with surgical exploration, depending upon the likelihood of hemorrhage or visceral injury.
In our practice, we do not give prophylactic antibiotics for patients with suspected uterine perforation. We treat with antibiotics only if clinical signs of infection are present (eg, endometritis, peritonitis). No studies have addressed this issue.
Candidates for observation — If uterine perforation is thought to have occurred during cervical dilation or with a blunt instrument with no suction or electrosurgical energy source, the risk of vascular or visceral injury is low and close observation may be sufficient [3,11]. The patient should be monitored for signs of intraperitoneal hemorrhage (eg, hypotension, dropping hematocrit, increasing abdominal distension) or visceral injury (increasing abdominal pain or tenderness, abdominal distension). This may reasonably occur in the recovery room over several hours. A baseline hemoglobin and hematocrit (if not already performed) may be obtained and then repeated in three to four hours. A stable patient may be discharged home with strict instructions to immediately report any increase in pain, fever, abdominal distension, or bleeding.
Criteria for surgical management — Abdominal exploration should be performed immediately if there are signs of severe uterine bleeding or vascular or visceral injury are suspected. As an example, vigorous vaginal bleeding should prompt a pelvic examination to exclude a cervical laceration, followed by abdominal exploration.
If electrosurgical energy, morcellation, or suction curettage were utilized during the procedure and perforation is suspected, the potential for serious injury is increased. In such patients, immediate abdominal exploration should be performed.
Any intrauterine device or other foreign body that has entered the peritoneal cavity should be removed.
Abdominal exploration — Among patients who require abdominal exploration, laparoscopy is preferred if the patient is stable since the risks of perioperative morbidity are lower. A meta-analysis of 27 randomized clinical trials comparing operative laparoscopy with laparotomy for benign gynecologic conditions found the overall risk of minor complications (eg, fever, wound or urinary tract infection) was significantly lower in patients undergoing laparoscopic procedures . In addition, recovery time is shorter after laparoscopy. However, it is difficult to evaluate the entire bowel at laparoscopy and an experienced operative laparoscopist is needed to accomplish both evaluation and repair using laparoscopic instruments (see "Overview of gynecologic laparoscopic surgery and non-umbilical entry sites", section on 'Laparoscopy versus laparotomy'). Consultation with a general surgical colleague is recommended if there is concern for bowel injury, either electrosurgical or mechanical. General gynecologists may not be sufficiently experienced to undertake this assessment.
Laparotomy may be warranted in patients who are not hemodynamically stable. Once the abdomen has been entered, initial inspection should include identifying the site of uterine perforation and assessing for injury to adjacent structures.
The patient should be kept in a stable position to avoid movement of bowel loops away from the area. This is true for evaluation by either laparoscopy or laparotomy. Retaining the "at risk" loops of bowel in the pelvis will facilitate identification of injuries. Hemorrhage into the bowel wall or blanching of the bowel if energy sources were used may reflect bowel injury.
Areas of brisk bleeding from the uterus or vessels should be controlled immediately. Bleeding from the uterine site can be stemmed using injection of intramyometrial vasoconstrictors (as with myomectomy), sutures, or electrocoagulation. Large perforations (>1 cm) should be reapproximated with suture. Depending on the site and extent of injury, resection of the perforated uterine segment may be necessary for repair . Failing these measures, hysterectomy may be needed; selective uterine artery embolization is an alternative [3,9]. Consultation with an interventional radiologist, if available in the facility, may be helpful prior to proceeding with hysterectomy in cases of brisk bleeding from the perforation site or for management of active retroperitoneal bleeding.
Retroperitoneal injury may be difficult to recognize. The surgeon should look carefully for enlarging retroperitoneal hematoma formation.
If injury to the bowel, bladder, or major vessels has occurred, consultation with a general surgeon, vascular surgeon and/or a urologist is helpful when determining the extent of, and repairing, the injury.
Completing the original procedure — If uterine perforation occurs with a blunt instrument with no suction or electrosurgical energy source, the original procedure can be completed under ultrasound guidance (also without use of suction or an energy source), and the patient can be observed.
Another option is to complete the procedure under laparoscopic guidance. Laparoscopy allows for direct visualization of the perforation site and retraction of surrounding structures.
Postprocedure monitoring — Patients with uterine perforation will likely experience mild cramping or light bleeding. Acetaminophen or nonsteroidal anti-inflammatory drugs are usually adequate for postoperative pain control.
Patients should be advised to call their clinician if pain is severe or persistent, vaginal bleeding is heavy, or there are other symptoms of ongoing complications of uterine perforation (eg, hematuria, abdominal distension, fever). Delayed presentation of bowel perforation following unrecognized uterine perforation has been reported  (see 'Postprocedure clinical manifestations' above). Any patient who calls with concerns or increasing symptoms postoperatively should be seen and evaluated promptly.
The patient may resume most normal activities within 24 hours and should follow standard postoperative instructions for gynecologic procedures. (See "Patient education: Care after gynecologic surgery (Beyond the Basics)".)
We see patients for a follow-up visit one week following the procedure to assess for further complications.
DELAYED PRESENTATION — Uterine perforation should be suspected in patients who have undergone an intrauterine procedure and who present with symptoms of visceral or vascular injury, although such complications can also occur without uterine perforation (see 'Postprocedure clinical manifestations' above). Some complications, including bowel injury, can present as late as three weeks after the procedure , while fallopian incarceration can present with persistent pain at even longer intervals .
Patients with delayed diagnosis of uterine perforation typically present with an associated complication (eg, anemia, peritonitis) and need evaluation for the presenting complication rather than confirmation of the uterine perforation itself. Patients who present after an intrauterine procedure with nonspecific abdominal pain with no signs of hemorrhage or visceral injury do not need to be assessed specifically for uterine perforation, although the possibility of perforation and visceral injury must always be considered when approaching these patients.
Hemorrhage due to uterine perforation is likely to present perioperatively, and thus, it is generally recognized before the patient leaves the hospital or clinic. This may result from severe injury to the uterine wall or a blood vessel. On the other hand, patients with occult retroperitoneal or intraabdominal bleeding (eg, a slowly expanding retroperitoneal hematoma) may not become symptomatic until several hours after a procedure.
Visceral perforation can present either acutely or hours to weeks postprocedure. Fever, in particular, is a delayed sign that may result from an infection of the reproductive organs (eg, tubo-ovarian abscess), bowel, or urinary tract (eg, peritonitis).
Evaluation — If a complication associated with uterine perforation is suspected, the patient should be evaluated with vital signs and a pelvic and abdominal examination. If bleeding is suspected, laboratory evaluation includes a hematocrit and coagulation tests. If peritonitis or urinary tract infection is suspected, a white blood cell count and urine or blood cultures are also collected.
Uterine perforation cannot be confirmed or excluded with any imaging study. In patients with anemia, fever, and/or pelvic mass or tenderness, pelvic ultrasound is the test of choice to identify a broad ligament or retroperitoneal hematoma or a tubo-ovarian abscess and can also exclude some other etiologies of pelvic pain.
If bowel or bladder injury are suspected, appropriate abdominal or urinary tract imaging should be performed. The evaluation of patients with suspected bowel or urinary tract injury is discussed in detail separately. (See "Blunt genitourinary trauma: Initial evaluation and management", section on 'Primary evaluation and management' and "Overview of gastrointestinal tract perforation".)
If fallopian tube incarceration is suspected, hysteroscopy and laparoscopy are performed for diagnosis and management [6-8].
Management — Specific complications should be treated as appropriate (eg, transfusion, antibiotic therapy, surgical repair of a perforated viscus). If abdominal exploration is performed, the uterus should be inspected for a perforation site. The absence of a visible defect does not exclude a previous uterine perforation, since small defects may have closed spontaneously subsequent to the procedure. However, if a uterine defect is visible, it should be closed to prevent future intraperitoneal infection or bowel incarceration.
EFFECTS ON FUTURE REPRODUCTION — A uterine perforation, like any uterine incision, is likely to heal well. Adhesion formation is possible, however, no adverse effects of uterine perforation on fertility have been reported.
Uterine perforation may weaken the uterine wall and raises concerns for an increased risk of uterine rupture during subsequent pregnancy [25-27]. The largest literature review regarding this issue identified 18 reports of uterine rupture in patients who had a prior operative hysteroscopy, 10 of these patients had a uterine perforation during the hysteroscopy; however, these patients also had other risk factors for rupture (eg, extensive hysteroscopic resection of a septum or adhesions and/or electrosurgery) . A subsequent systematic review found 14 additional case reports of uterine rupture in pregnancy after an intervention complicated by uterine perforation . Further high-quality studies are needed.
We counsel patients who have had a uterine perforation that there may be some elevated risk of uterine perforation in a subsequent pregnancy, but that the risk is likely minimal in the absence of other risk factors. We do not advise cesarean birth for patients with a uterine perforation who did not undergo a concurrent metroplasty, intrauterine adhesiolysis, or myomectomy and have not had a prior cesarean birth. (See "Choosing the route of delivery after cesarean birth".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gynecologic surgery".)
SUMMARY AND RECOMMENDATIONS
●General principles – Uterine perforation is a potential complication of all intrauterine procedures. Injury to surrounding blood vessels or viscera (bladder, bowel) may result. Uterine perforations that are not diagnosed at the time of the procedure can result in hemorrhage or sepsis. (See 'Introduction' above.)
Perforation should be suspected with deep penetration of instruments, loss of visualization, excessive bleeding, or the identification of fat in the cavity or the curettage specimen. (See 'Evaluation' above.)
●Risk factors – Factors that make access to the endometrial cavity difficult or alter the strength of the myometrial wall predispose to uterine perforation (eg, cervical stenosis, uterine malposition, pregnancy, menopause). (See 'Risk factors' above.)
●Cervical preparation – For some patients, cervical preparation (eg, misoprostol or laminaria) may be used prior to the gynecologic procedure (eg, hysteroscopy, dilation and curettage [D&C], intrauterine contraception, pregnancy termination) to decrease the risk of uterine perforation. This is discussed in detail separately. (See 'Cervical preparation' above and "Overview of hysteroscopy", section on 'Cervical preparation and dilation' and "Dilation and curettage", section on 'Cervical preparation' and "Intrauterine contraception: Insertion and removal", section on 'Misoprostol' and "Pregnancy termination: Cervical preparation for surgical procedures".)
●Difficult cervical dilation – For patients in whom cervical dilation cannot be accomplished using mechanical dilators with gentle pressure, we suggest further attempts be performed under ultrasound guidance (Grade 2C). (See 'Difficult cervical dilation' above.)
●Candidates for observation – For patients with suspected or confirmed uterine perforation that occurred during cervical dilation or with a blunt instrument and who are hemodynamically stable, we suggest observation rather than immediate abdominal exploration (Grade 2C). (See 'Candidates for observation' above.)
●Patients requiring surgical management
•Abdominal exploration is required for patients in whom perforation occurred during use of electrosurgical energy or suction curettage, who are hemodynamically unstable, or in whom there are signs of severe bleeding, or vascular or visceral injury are suspected. (See 'Criteria for surgical management' above.)
•For patients with uterine perforation who require abdominal exploration and are hemodynamically stable, we suggest laparoscopy rather than laparotomy (Grade 2B). Use of laparoscopy depends on the availability of a surgeon who can adequately assess the bowel laparoscopically. Immediate laparotomy is generally necessary for patients who are not hemodynamically stable. (See 'Abdominal exploration' above.)
●Effects on future reproduction – Uterine perforation may weaken the uterine wall and raises concerns for an increased risk of uterine rupture during subsequent pregnancy. However, this risk is likely minimal in the absence of other risk factors (eg, extensive hysteroscopic surgery, transmural myomectomy, previous cesarean birth). We do not advise cesarean birth for patients with a uterine perforation who have no other risk factors for uterine rupture. (See 'Effects on future reproduction' above.)